Authors: Dr. Faisal Shuaib, Akachi Mbogu, Muhammed Sheriff, Dr. Bassey Okposen, Dr. Murtala Bagana, Dr. Garba Bakunawa, Fatima Ambashair Kyari, Dr. Owens Wiwa, Dr. Sebastian Ilomuanya
Nigeria, like most low and middle-income countries, is supported by donors to fill the gaps in the health system. This support ranges from technical and managerial assistance to reach global and country strategic goals, to financing the procurement of critical equipment, supplies, and activities for an equitable and sustainable health system. For instance, Gavi, the Vaccine Alliance, has provided over $732,130,326.00 to Nigeria since 2001 for vaccines and cold chain procurement, technical assistance, immunization campaigns, and health systems strengthening. However, with Nigeria’s Gross National Income (GNI) per capita exceeding the current Gavi threshold of support of $1,580 GNI for three consecutive years, Nigeria entered the accelerated phase of the Gavi transition in 2018 with the expectation of becoming fully self-financing by 2028. To succeed in this transition, Nigeria’s immunization program will need to navigate several financial and programmatic risks to its sustainability.
There are four major “shocks” that could affect the country’s ability to sustain high coverage and equity during a transition from Gavi support. The shocks include A) loss of Gavi subsidies for vaccines, often the most significant cost driver of the immunization program, B) loss of Gavi cash support for immunization system strengthening, which includes operational costs, C) loss of guaranteed access to Gavi vaccine prices and procurement channels, and D) loss of technical and managerial support; performance management incentives and support; and political support from Gavi or other partners. If not adequately prepared, Nigeria may lose the gains made in strengthening immunization and the entire health system.
To sustain the country’s gains and maintain the quality of primary health care service delivery following Gavi’s investments, the Government of Nigeria, through the National Primary Healthcare Development Agency (NPHCDA), developed Nigeria’s Strategy for Immunization and PHC System Strengthening (NSIPSS) in 2017. The NSIPSS is a 10-year strategy document that defines the country’s plan to transition from Gavi support. This plan, which was developed in collaboration with partners, highlights the financial and programmatic decisions that Nigeria will need to make to attain at least 84 percent equitable and sustained national immunization coverage for all antigens by 2028. The transition plan initially started as a 5-year strategic plan (2017 – 2021) but eventually became a 10-year plan following negotiations with Gavi.
We share some of the critical lessons from Nigeria’s experience in developing a Gavi transition plan, which could help countries plan for the transition and transition extension from one donor support or the other.
How did Nigeria develop the Gavi transition plan?
Nigeria constituted five working groups that focused on developing the plan and submitting it to Gavi for approval over three months. Nigeria considered financial and programmatic implications when determining a realistic timeline for a successful transition from Gavi support. These implications include 1) the target coverage to achieve at the end of the transition period; 2) the programmatic decisions around the interventions to be implemented; 3) the country’s finances; and 4) political leadership.
In developing the NSIPSS, Nigeria set a goal to reach a more realistic high coverage target for most routine antigens, specifically, 84 percent coverage for the third dose of the DPT vaccine, which protects children from diphtheria, tetanus, and pertussis (whooping cough) simultaneously, by 2028. This decision was based on modelling historical survey data, which showed that it would take ten years from 2018 to achieve that level of coverage, while, at the same time, introducing new lifesaving vaccines. The modelling also considered the interventions selected to achieve this goal. The country opted to use evidence from successful pilots or tested interventions, which would speed up coverage rollout, rather than running new pilots.
Nigeria also considered the fiscal space, defined as the budgetary room that allows a government to provide resources for public purposes without undermining fiscal sustainability, within which the transition plan will be funded. With the support of partners like CHAI, The World Health Organization (WHO), The United Nations Children’s Fund (UNICEF), The Bill and Melinda Gates Foundation, other immunization partners, and local Gavi consultants, the government conducted a fiscal space analysis to identify funding sources to help determine program budget projections. The analysis considered the country’s tight fiscal space at the time due to recession, coupled with the transition from other global aid sources, such as the Global Polio Eradication Initiative (GPEI).
Finally, the decision also considered the country’s political economy, with elections on the horizon that could result in a change in government, which may have different priorities. The NPHCDA identified key political stakeholders at the highest level of government, including the Presidency who were part of the bureaucracy and less likely to change with political party changes, and engaged these leaders as champions to drive the government’s commitment.
Six critical elements were essential in developing Nigeria’s transition plan. These include:
1. Stakeholder Engagement
Stakeholder engagement is critical to developing country ownership, leadership, and sustainability of the program moving forward. In Nigeria, the NPHCDA invited professionals from multiple sectors – beyond immunization and even health – to join a government-led forum whose goal was to ensure sustained commitment and accountability to immunization financing. Stakeholders included the Ministry of Finance, Ministry of Budget and National Planning, the National Assembly, Governors Forum, Commissioners, Donors, Partners, and Civil Society Organizations, as well as frontline health workers who are vital to the implementation of the plan at the sub-national level. Based on stakeholders’ various areas of expertise, the government set up five technical working groups. These groups focused on:
- Strategy review: Review current documentation and identify areas that need strengthening.
- Finance: Conduct financial resource requirement assessments, develop home-grown financing models, and address accountability, transparency, efficiency, and equity in resource allocation between levels of government.
- Engagement: Ensure effective engagement of all key stakeholders.
- Workplan: Collate activities from teams to develop a workplan and track implementation of activities.
- Secretariat: Provide secretarial support and follow up with working groups on specific action points and deliverables.
The government provided the working groups with detailed terms of reference that defined the deliverables and members’ roles and responsibilities. The government also ensured the regular participation of all stakeholders through frequent engagement.
Lesson learned: Adequately plan and establish a robust coordination mechanism that provides an opportunity for frequent stakeholder engagement at an early stage. This coordination mechanism will guide the government and partners towards the development of the transition plan. Following the development of the transition plan, the functions of this coordination mechanism are to be transitioned to existing government coordination mechanisms known as the Vaccine Financing and NSIPSS Accountability Task Team situated within the NPHCDA.
2. Advocacy and Political Commitment
Strong advocacy and political commitment played a vital role in making change happen in the immunization and primary health care (PHC) system. In the development of the NSIPSS, there was a change in the leadership of the NPHCDA that ensured that Gavi and other partners were willing to re-engage with Nigeria. This new NPHCDA leadership, in collaboration with the Minister of Health, engaged key stakeholders within and outside the health space that played a crucial role in the process. The groups included the Presidency, the Senate Committee on Health, the Nigeria Governors’ Forum, Ministers of Budget and Finance, and the Director-General of Budget and National Planning. These stakeholders ensured timely approvals, oversight, and accountability, ensuring states provided operational funds for immunization, with the Nigeria Governors’ Forum playing a crucial role in getting the buy-in of the states. They also proposed and approved sustainable financing strategies for immunization and PHC based on the country’s fiscal realities. On an annual basis, a high-level review meeting is held with a broader group of relevant stakeholders to review progress made on the NSIPSS and accountability framework against annual targets. This review helps demonstrate accountability to commitments by all involved.
Lesson learned: Strong political will obtained from the highest government level, especially the Presidency, is critical to ensuring the financial and programmatic commitments are met within the stipulated timeline. It is recommended to engage the highest level of government early with credible leadership at the implementation level to drive commitments and accountability.
3. Quantification and Forecasting
In planning for transition, it is crucial to determine and estimate the needs to sustain the program financially and programmatically. To facilitate these efforts, the government, with support from implementing partners, conducted a quantification and forecasting of vaccine needs and cost estimates for the transition period 2018 to 2028. The government relied on historical vaccine consumption and performance to determine vaccine requirements. Nigeria also adopted a buffer system to mitigate against vaccine stockouts. States with a vaccine target coverage of less than 60 percent received a 50 percent buffer stock, while those with coverage equal to or above 60 percent received a 25 percent buffer stock. It is more likely that states with lower targets will exceed their planned coverage; they received a more significant percentage of extra vaccine stock.
Lesson learned: Determine and align on a financial model for quantification and forecasting considering previous program performance and strategies to reduce wastage and improve accountability. In countries with unreliable data systems, historical vaccine coverage data provides a realistic baseline to guide future vaccine requirements. It is vital to plan for additional buffers and mechanisms for emergency procurement and distribution to minimize stockouts. The availability of accurate data for previous years will significantly improve the quality of this process.
4. Health System Strengthening
For Nigeria to increase immunization coverage equitably while transitioning from Gavi support, the NPHCDA developed strategies to link immunization to the delivery of other health services. This involved integrating routine immunization with the broader PHC integration agenda to improve resource pooling and efficiency in program implementation. For example, the NPHCDA, in collaboration with partners, developed the Optimised Integrated Routing Immunization Session (OIRIS) strategy. The approach was successful as PHC was a government priority with several interventions already planned to improve service quality at primary health centers for all programs. The areas targeted by the NSIPSS interventions at both the facility and community levels include strengthening governance through the Primary Healthcare Under One Roof (PHCUOR) initiative, human resources, infrastructure, financing data management, and demand creation.
Lesson learned: In resource-constrained settings, consider adopting a health system approach to improve resource pooling, program implementation efficiency, and sustainability.
5. Enhanced and Sustainable Financing
With donor transition comes the loss of funds to finance critical aspects of the health system and increased financial burden on the government. This was a huge challenge in Nigeria considering the already tight fiscal space, which was further complicated by an economy in recession, high inflation rates, low revenue, and increasing population, not to mention ongoing disease outbreaks. The NPHCDA, with the support of partners, took all these factors into account in determining the current and future financial outlook through a fiscal space analysis that explored ways to expand the national health budget sustainably. The NPHCDA also determined the programmatic requirements for routine and new vaccine procurement and immunization campaigns, developing a financing model that mapped donor and government contributions for these operations as Nigeria transitioned. Based on this, Nigeria proposed a strategy to realistically finance the transition plan through World Bank loans, donor support, statutory budget, and ring-fencing funds for immunization through the Basic Health Care Provision Fund (BHCPF), the service-wide votes in the short term, and the first-line charge in the longer terms. Nigeria committed to these strategies in a letter sent to Gavi for accountability.
Lesson learned: Understanding a country’s fiscal space, financial complexities, and health system helps determine realistic financing strategies and timelines for vaccine program operations. It is recommended for countries planning transition to conduct a fiscal space analysis to determine available funding sources and realistic financing strategies.
6. Defined and Clear Accountability Framework
The accountability framework is one of Nigeria’s NSIPSS transition plan’s most critical elements as it demonstrated the governments’ commitment to financial and programmatic accountability. The accountability framework defined key indicators for accountability and expected rewards and sanctions based on Gavi’s Principles of Engagement. The principles of engagement required the government to demonstrate commitments in the form of reimbursement of misused funds; increases in year-to-year health budgetary allocations; improved programmatic equity focusing on areas with low coverage; adequate monitoring, evaluation, and implementation research; and demonstrated ability to transition polio eradication resources effectively.
Nigeria derived five components for the Gavi transition plan comprising 15 indicators to show the government’s commitment. These indicators are reviewed annually by high-level government officials and Gavi leadership to inform ongoing support and course corrections. They included:
- Core indicators (1): Outcome of annual external audit and Gavi country program audit and timeliness of the release of funding for traditional and co-financed vaccines.
- Health financing indicators (2): Vaccine financing, PHC financing, and overall health sector financing.
- Financial management and institutional capacity indicators (3): Financial management capacity building and adequate financial management arrangements.
- Governance indicators (4): Expansion of Presidential Task Force on Polio Eradication to PHC, expansion of Inter-Agency Coordination Committee (ICC) to NSIPSS oversight, and partner alignment with the national plan.
- Programmatic performance indicators (5): Vaccine coverage, vaccine accountability, and data quality.
These indicators were jointly agreed upon by the Government of Nigeria, donors, and relevant stakeholders and approved for use to ensure the commitments made in the NSIPSS are met.
Lesson learned: Having a clear and defined accountability framework provides the overall architecture for mutual accountability of government, donors, and partners to enhance ownership and promote transparency across the system. In adopting this approach, the framework’s indicators should be realistic and based on country context with all stakeholders and partners’ involvement. It is also essential to establish an annual forum chaired by the government’s highest level to conduct a review of the accountability framework.
In conclusion, countries receiving donor support will experience a transition period when the donor support ceases. The ability of a country to withstand this period of “shock” and achieve better health outcomes is dependent on the transformative investments made during the transition period. This requires careful planning involving all stakeholders within and outside the health sector and establishing functional systems for coordination, implementation, monitoring, and evaluation. The development of a transition plan is only a means to an end and not an end.
This blog was co-authored by Dr. Faisal Shuaib1, Akachi Mbogu2, Muhammed Sheriff2, Dr. Bassey Okposen1, Dr. Murtala Bagana1, Dr. Garba Bakunawa1, Fatima Ambashair Kyari1, Dr. Owens Wiwa2, Dr. Sebastian Ilomuanya2
We would like to acknowledge the contributions of the different development partners and agencies in Nigeria that supported implementing the work reported here.
- National Primary Health Care Development Agency
- Clinton Health Access Initiative
The scale and nature of Gavi’s support changes as GNI per capita increases over time. This means that when countries move from initial self-financing to accelerated self-financing phase based on their GNI per capita, Gavi gradually begins to reduce the support to these countries until they enter the fully self-financing phase when Gavi withdraws all support
 Between May 2017 – Sep 2017, Nigeria developed the first transition plan with the support of a consulting firm. However, Gavi requested the country to work with Gavi Alliance partners and relevant stakeholders to develop a new plan. Following this, the country constituted three working groups to develop the new transition plan over three months (Jan 2018 – Mar 2018. This plan was approved by Gavi Board in June 2018
 OIRIS strategy is a multi – pronged, system wide, strategy for improving routine immunization in poor performing areas focused on improving the effectiveness and efficiency of fixed and outreach RI sessions and integrating these sessions with other PHC services thereby providing clients the opportunity to receive a wide range of interventions during their visit to the clinic for routine immunization.
 BHCPF is a fund that represents 1% of Nigeria’s Consolidated Federal Revenue, which makes supply- and demand-side investments for Primary Health Care, including immunization
 The service wide vote is a contingency budget constituting 5% of the annual budget operated under the constitution of Nigeria. It is statutorily used to pay for items not included in the annual budget and released from the vote with legislative approval. Expenditures from the vote must be immediately replenished through supplementary estimates and appropriation bills
 First line charges are statutory deductions made in the Federal Account before distribution to other needs and the tiers of the government. Items in the First Line Charge are determined by an act of parliament