Welcome Boost for Routine Vaccination through Pragmatic Financial Management

Vaccination is one of the most cost-effective, life-saving public health interventions available. In Nigeria, the dual challenge of low coverage and inequitable access, particularly in the northern part of the country, has led to low immunization coverage, making the populous nation one of the largest contributors to the global burden of vaccine-preventable illnesses and deaths (VPDs).

The country’s polio eradication program was launched towards the end of the 1990s and in the following decades, close to 200 mass campaigns were carried out across the country, especially in the north, in the fight against the crippling disease. Though polio was the main target of these immunization efforts, health authorities claimed that routine immunization coverage was also increasing. Yet 15 years into the program, Nigeria still had a very high burden of vaccine-preventable diseases.

Prior to 2012 and 2015 in the case of some states, despite a significant level of internal and external investment, it was clear that the routine immunization program was not reaching under-served populations. A new approach was required in order to fully protect children against the full complement of vaccine-preventable diseases while simultaneously increasing immunization against polio.

HURDLES TO HEALTH

Lack of political will, insufficient organizational capacity and inadequate funding were some of the biggest barriers to the success of routine immunization, and the root cause of many weaknesses in the system. In northern Nigeria in particular, the situation was exacerbated by cultural and social issues, including low literacy levels and poverty. For many families, health could not be a priority when food and survival took center stage. Elements of weak leadership, a system that was not politically driven to prioritize and effect positive health changes and a populace that was insufficiently informed about and highly distrustful of health services resulted in persistently low uptake of immunization. It was also clear that there was a need for delivery of other life-saving vaccines in high-risk communities that were fatigued by repeat campaigns that offered only polio drops.

Recognizing these challenges and barriers, a team was created to carry out a diagnostic assessment at all levels of the health systems of Kano, Bauchi, Borno, Kaduna, Sokoto and Yobe states which had some of the poorest immunization indicators. The assessment included a desk review of program data; interviews with immunization managers and partners to understand the challenges and gaps in the system; and an analysis of how immunization could become an entry point to strengthening the primary healthcare system. Next was an analysis of the costs and a review of the budgetary and financial systems needed to support the program.

The results of this assessment indicated that poor financing and weak financial management were significant and silent drivers of low immunization across the country. In many state health agencies, there was no budget line for routine immunization, neither were there adequate funds for routine immunization activities. Where funds were released, there were no accountability systems to ensure transparency of funds flowing across levels, often leaving room for leakages and diversions as cash was moved physically from hand to hand.

Furthermore, there were long lag times between funds requisition, approval and disbursement, lack of clarity in balancing of accounts, and with an inadequate paper trail to ensure financial control and compliance. The weak financial management systems facilitated the leakage of the available meager resources, with little or no repercussions, while mismanagement and misallocation of funds left few resources for primary health care delivery. Funds allocation was left to health managers at the lower levels of the health system and with an inadequate paper trail, there was little accountability. The procurement process and eventual awarding of contracts was plagued with irregularities. In addition, though partners such as WHO and UNICEF directly funded ad hoc specific health activities, including immunization, there was no designated government funding to safeguard routine immunization implementation.

In recognition of these issues, the Bill & Melinda Gates Foundation and the Aliko Dangote Foundation (ADF) signed multipartite agreements with the individual state governments to strengthen sustainable health financing, governance systems, vaccine supply chains, service delivery, and community engagement with the ultimate aim of reducing childhood deaths due to vaccine-preventable diseases.

The agreements required the state governments to dedicate a line item in their budgets every year for routine immunization, and utilized a funding structure that allowed for pooled funding for the routine immunization (RI) program (via a shared basket fund). This gave specific funding responsibilities to each signatory over the period of the agreement, based on estimates of what it would cost to have a fully functional, at-scale state immunization program. The first step was to identify all the bottlenecks and estimate how much it would cost to try and sustainably resolve them. Capital and recurring expenses and the systems and processes that guided them all had to be taken into account. This process gave a clear estimate of the minimum cost needed in place for success to happen. The foundations also engaged committed partner agencies to provide technical assistance to State Primary Health Care Development Agencies (SPHCDAs) to strengthen their capacity to manage the RI basket funds as well as other program funds efficiently and transparently.

The Solina Center for International Research and Development (SCIDaR), a not-for-profit firm that works with governments, donors and private sector to characterize and address development challenges, was engaged to provide management support to the state governments for the implementation of the MoU. With expertise and experience working to strengthen health systems, SCIDaR’s assignment included the redesign of the vaccine logistics architecture to ensure direct last-mile vaccine delivery in each of the states, supporting and facilitating the procurement of cold chain equipment, and making sure that it was installed in the right places and functioning optimally; and later, providing full-scale management technical support to monitor the implementation of this initiative across all program themes.

The multipartite agreement was designed in such a way that, over time, state contribution to the routine immunization funding would increase gradually as that of Aliko Dangote Foundation and the Gates Foundation decreased, with the eventual aim of each state fully funding its routine immunization program. For example, in the first year in Bauchi state, the government was expected to provide 30% of the funds needed while the foundations would provide the remaining 70%, with the government gradually taking on larger proportions over time.

The funding contributions by the parties were put in a joint account called the MoU “basket fund”, which was controlled by the SPHCDAs. The agreements were also structured to allow the huge capital expenditure – such as purchase of vehicles for logistics, installation of solar fridges and renovation of health facilities to house the solar refrigerators – to be done early. This front-loading meant that the foundations could cover a larger proportion of expenses and allow each state to gradually take over full financial responsibility for its program, by concentrating on operational and maintenance costs. The hope was that this innovative funding arrangement would compel state governments to commit the time, workforce and money necessary to strengthen routine immunization. To further ensure high-level oversight and sustain political buy-in, the agreement established bi-annual reviews with the foundation Principals, monthly and in some states, bi-monthly State Task Force on Immunization meetings with the Deputy Governors and other political and traditional leaders, to hold the SPHCDA leadership accountable for program fund expenditures, as well as review program results.

Implementation of the plan outlined in the MoU agreement began in 2012, with RI being identified as an entry point for broader primary health care strengthening. The most populous of state was Kano which also had the highest number of un-immunized and under-immunized children, yet it had a state leadership with strong political will to transform its immunization and PHC programs. Lessons learned from Kano would then be used to scale up the initiative to the five other high-burden states. The approach adopted was “if we can get it right within the complexity of Kano, we can get it right elsewhere”. Once the program had progressed in Kano, Bauchi was brought on board in 2014, and the other four states by the end of 2015.

UPGRADING PROCESSES AND TRAINING PERSONNEL

The SPHCDAs and their partners formed working groups which were responsible for developing work plans and budgets. The work plans from each group were then collated upwards to the overarching RI working group, which reported to the SPHCDA leadership. The RI working group was also charged with ensuring that the funds were reflected in the state health budget and ring-fenced to guarantee their availability, an undertaking that required significant advocacy by the state immunization teams and donors to secure buy-in of the governor and parliaments. Once the budget was approved, the team pushed to ensure that the funds were released. This was informed by the prevailing health financing data, where states often allocated less than the recommended 15% of their total budgets to health, and released significantly lower amounts of the funds for implementation due to the lack of dedicated resources for specific health-related activities. To motivate the government to allocate the money for immunization, the Gates Foundation deposited its contribution into the basket fund early, and urged the state to pay its share which was required before the Aliko Dangote Foundation made any contributions. Making the Aliko Dangote Foundation funding contingent on the state playing its part was both a point of encouragement and leverage. In addition, the fact that Aliko Dangote – the Foundation’s namesake – is from Northern Nigeria made the advocacy efforts easier because he had personal relationships with many of the leaders involved, which the team leveraged to the program’s advantage. The figure below shows the contribution pattern for one of the MoU states.

To ensure that money went where it was needed, it was important to put systems in place to move the funds from state level to the health facilities, bypassing the intermediary Local Government Authority (LGA) level. As it turned out, most of the health facilities offering routine immunization did not have bank accounts and so across the six states, over 4,500 bank accounts needed to be opened, a huge bureaucratic undertaking. Each account had two signatories – a health worker and either someone from the existing ward development committee or the person in charge of the health facility – who had to sign o each time funds were to be collected. A disbursement schedule was then developed with the names of all facilities, account numbers and amounts to be sent, guided by micro-plans that were developed by each facility.

To get the system to work, health workers were trained on how to access the funds, how to sign checks and how to fill in fund retirement forms every month to account for money used. Nothing was left to chance. During each outreach mission, a community leader and an immunization client signed o to verify that services had been provided. Accountants from 149 LGAs were also trained on the collation of facility retirement forms and the retirement of administrative funds received at the LGA level.

Capacity building at the state level focused on operating the financial management system, targeting Directors of Administration and Finance, internal auditors, cashiers and accountants. Where these positions were vacant, administrative transfers of suitable personnel from other ministries or agencies was done to ensure that there were no gaps.

To facilitate the capacity transfer, SCIDaR deployed experienced finance analysts versed in international best practices and processes, who spoke the local language and had a good understanding of the context of the state, to coach the state finance teams. After the intensive training and on-the-job coaching, the state teams were able to use the system independently and efficiently. LGA health accountants were for the first time able to follow up on budget use, rather than just signing for release of funds. It is important to note that, while the training was initially focused on immunization, the ultimate goal was to transfer these lessons to a broader PHC application for managing, tracking and auditing funds.

Huge investments were being made by partners and donors in primary health care in their states, so minimal contributions from the state coffers would bring into question their commitment to helping their own people. The influence, convening power and active participation of the high-profile foundation principals also helped to facilitate and sustain buy-in of these partnerships. While the latter incentive was not necessarily tied to improving health care, it yielded the desired results of getting the state leaders wholly committed to the routine immunization program and holding the health managers accountable for the results. This commitment has been retained, as evidenced by the current situation in Kano and Bauchi, both of which have fully transitioned to funding 100% of the routine immunization program independent of the two foundations, with the multipartite approach expanded to focus more broadly on PHC.

The state leaders were incentivized by the fact that donor organizations were putting their money directly into government accounts but this also meant that systems needed to be put in place to manage the funds and ensure they were spent correctly. The states were keenly aware that the base amount of external resources for each year would reduce as the memorandum of understanding progressed, motivating them to put their energies into ensuring sustainability of funding for their immunization programs.

It would appear, then, that the innovative strategies employed by the program successfully secured two of the most sought-after elements in health development – political will and dedicated financial resources. The heavy lifting upfront to get the system in place paid o significantly, as did engagement of expertise from non health areas focused on financial management, costing and budgeting. The involvement of the Aliko Dangote Foundation and Gates Foundation was key to the success of the implementation in the six states, but it is also encouraged other governors to set up similar systems without financial backing as they recognized that good health makes good politics.

The ongoing documentation of the MOU implementation and completed start-up guides will be useful resources for other states and countries interested in setting up similar approaches for routine immunization or other programs. But states do not have to follow the exact same route. The initial proof-of-concept approach required flexibility enabled, but now that it is working, states can fund their own routine immunization using a program rather than a project approach – which was a key objective of the MOU. The agreement in Bauchi State, for instance, was quadripartite because USAID was also a partner, although it did not contribute to the basket fund, but rather supported and funded critical activities through a third party technical assistance provider who was accountable for USAID contributions. The Global Fund for Malaria, TB and HIV also joined the Kaduna MOU. And when the initial MOU period ended in 2018, UNICEF joined the partnership as a basket account funder, which required deliberations to ensure that the arrangement did not violate UN financial guidelines. In the end, it was agreed that the money would be used for more than just immunization, and would go towards strengthening primary health care.

Notably, encouraged by the financial transparency and accountability of the system, other international development organizations have expressed interest in replicating the program for different interventions, and discussions are ongoing on how to do so. In fact, as a result of the successful implementation so far, Gavi, the Vaccine Alliance, Global Affairs Canada, and other international NGOs are also leveraging the lessons learned from the MoU implementation to explore implementing similar models in other states and countries.

There is still work to be done to streamline financial management in mass immunization campaigns, which are not subject to the terms of the MOUs but done via an ad hoc arrangement and implemented as a vertical program. As this process is streamlined, there is space for these campaigns and provision of other public health services to piggyback on the routine immunization financial system which has resulted in an updating of the RI MOU financial management system to reflect the realities of PHC evolution. For example, in some of the states, the implementation of Nigeria’s Basic Health Care Provision Fund will be building on the immunization financial management system with a view to integrate processes across all PHC funding streams. At the time of writing, three states have transitioned to PHC MOUs and have integrated RI within the broader PHC while conversations are ongoing for the remaining three states. Adjustments are being made and conversations are being had to institutionalize the system for broader healthcare provision and potentially other areas of development at state and national level. The experience and training of those managing the routine immunization financial process will come in handy for expansion and adaptation across other health service programs.

THE TIGHTEST BASKED WOVEN

The routine immunization financial management process sought to create a sound, layered system that both challenged and drastically changed the handling of finances across all levels of the state health system. On introduction, it sent shockwaves across a system where, for decades, issues with mismanagement of state coffers had posed a persistent challenge.

At the facility level, a set of tools was designed for the health workers to record their transactions as they happened. Two health workers from each facility were trained on how to fill the retirement forms and were required to attend monthly meetings to submit the forms. At first the health workers were unhappy about the extra task of having to fill the forms. An engagement plan was developed where the state reached out to facility health workers, LGA level officers and community leaders to get them to understand the importance of the accountability processes and to confirm how vigilantly the system would be monitored.

A validation process was put in place as an accountability measure to authenticate all submitted retirements by reaching out directly to the sites where the services were recorded as having been delivered and speaking with caregivers/beneficiaries and community leaders. The validation results were discussed with the state finance team, LGA accountants and LGA leadership where necessary, and shared with the health facility during monthly review meetings. Initially, the validation was done only at state level, but the process was gradually decentralized to LGA level in 3 of the 6 states, where account clerks were trained on how to conduct the validation with the involvement of the LGA level implementing partners for accountability, ensuring that there was no manipulation where retirement was not properly done. In addition, partners were able to regulate and track how money was withdrawn by the state health agencies. Quarterly workplans and budgets were sent to all MoU parties for no-objection. For any activity costing over N250,000 (US$645), all partners involved in the MOU had to give the go-ahead for implementation.

To strengthen accountability, focus was placed on solidifying the internal control system. On a quarterly basis, the internal auditor would evaluate the financial management processes and share a report with the agency leadership for prompt action. Similarly, an external audit was conducted annually, and the report shared with all relevant stakeholders in the routine immunization program in the state to ensure accountability. Over the years, 97% (87 of 90) of the audit exceptions across the 6 states have been implemented and 88% (111 of 126) of 2016 to 2019 audit exceptions were found to be unique exceptions buttressing the fact that the states have continually improved their internal control systems and successfully operate a transparent financial management system.

The accountability process was further reinforced by oversight from the state finance working groups, where each partner was represented. The group reviewed the MoU account statements, retirements and other financial activities on a monthly basis and made joint decisions on facilities that had defaulted on their retirements. This made it difficult for any party to manipulate the system. The MOU also clearly stipulated that default on any of the principles of financial management would be sufficient grounds for partners to pull out of the agreement. This placed the onus on the state to ensure that procedures were followed to the letter. Breaches that involved officials at state level were escalated right up to Foundation representatives, which served as a strong reputational deterrent against potential mismanagement.

A key accountability structure that made the change management easier was the expansion of the task force on polio eradication to a task force on immunization and subsequently immunization and PHC in every state. At the state level, this task force is chaired by the Deputy Governor with membership from the state officials, Traditional leaders, and representatives from partner organizations. Across the LGAs, the task force drew members from all levels of local government, including chairmen, traditional leaders and religious leaders. These task forces have enhanced ownership of the routine immunization program at state and local levels, with members holding the Primary Health Care Boards to account for usage of funds while actively monitoring activities on the ground. Biannually, Dangote, Gates and all the governors meet to discuss program performance, including the status of finances, how much of the funds are accounted for, and how many refunds have been received.

With such stringent structures, there is little wiggle room and anyone who would have been inclined to manipulate the system is less incentivized to do so. Indeed, at first there was pushback at the state and LGA levels, where cash used to be given to officials to conduct activities with no structures in place to verify the conduct of activities. The new, resilient system greatly reduced leakages and mismanagement. Those who tried to beat the system quickly found themselves in trouble: personnel who could not account for money allocated for certain activities were mandated to refund the monies to the MoU accounts or had the amounts promptly deducted from their salaries. So stringent are the measures that the basket account has been jokingly referred to as the tightest basket ever seen as nothing trickles through. The outcome of these effective controls is that the states have matured in their financial management and accountability processes, setting new standards for management and public accountability and most importantly, services are now reaching those who need them.

VOICE FROM THE FIELD

My name is Ibrahim Ahmed, Chief Administration Officer of the Bauchi State Primary Health Care Development Agency (SPHCDA). The agency manages the Finance Working Group and all the Primary Health Care financial management systems in the state.

Before the signing of the Routine Immunization MOU in 2014, Bauchi State was working with several partners
to provide immunization for its citizens, but there were serious challenges. Weak financial management processes, inadequate fund tracking mechanisms and poor leadership and governance of the program meant that immunization services did not reach children when and where they were needed.

Once the MOU was signed, we carried out an assessment exercise to identifygaps and challenges in the financial management system, so as to develop a blueprint guiding how we would address these problems. This met the terms of the MOU. The three-week exercise was carried out by a State Technical Finance Team with representatives from the oce of the Accountant-General, the Auditor-General, representatives of the Gates Foundation, Aliko Dangote Foundation, and development partners. The team made visits to some primary health care centers to evaluate the capacity required to manage funds and activities, and to determine the relevant processes, structures and training needed.

The major gap identified was that there was no line item for routine immunization in the SPHCDA budget. Money for immunization activities came mostly from donors and partners, while a small amount of funding was received from the local government into the joint account for logistical support. Inadequate funding made disbursement a huge challenge. Moreover, there were no standard retirement and validation tools to track use of funds. Work planning and budgeting, account management, retirement of funds and audit activities were non-existent or greatly inadequate.

Under the MOU, a basket fund was created for all resources contributed for RI-related expenses, including outreaches, review meetings and training. A routine immunization line item was created and a Finance Working Group, chaired by the SPHCDA’s Director of Administration and Finance, was set up to oversee the overall financial management of the immunization component. Members of the working group included representatives from Ministries, Departments and Agencies, the national health insurance scheme, the auditor general, MOU and implementation partners, and the Bauchi State Health Trust Fund.

An annual workplan and budget was developed, which was reviewed every quarter. In addition, bank accounts were opened at state, Local Government Authority (LGA) and health facility levels to facilitate direct electronic disbursement of funds from the state to facility level, where immunization activities took place, and to LGA level when necessary. This was a huge shift from the previous system, where cash would be collected from the state level for immunization activities on the ground, leaving the system open to fraud and delays. In contrast, use of the cashless electronic system has made the process much faster, safer and efficient.

The assessment also revealed a huge capacity gap. Consequently, training in financial management was done at all levels – from state to health facility level. All health facilities now have finance officers to manage the funds many of whom are health providers who have been trained in financial management. In 2018, because of the success in financial management of RI funds, was expanded to include funding for other aspects of primary health care, such as family planning, integrated management of childhood illnesses, and nutrition including leveraging the system for disbursement of the Basic Health Care Provision Funds (a national PHC funding mechanism). The trained finance ocers are able to manage the broader system. Periodic training continues in order to improve the system as it evolves. In fact, the state is transitioning to having a single account for all PHC activities, rather than separate accounts for each line activity, making it easier for the SPHCDA to manage the process of disbursement and tracking of funds.

Development of tools for retirement of funds at facility level, accompanied by spot checks, have been very useful for verification and validation of the work done on the ground. The retirement forms – simple templates for computerized reporting – are sent from the health facilities to the LGA accountant, who validates the data with development partners before sending them to state level. The tools have helped us to track activities to validate what has been retired, and to spot any anomalies in the reports. In 2017, for instance, we were able to detect that some activities had not been conducted on the ground as reported, yet funds had been disbursed. We instituted a refund process and recovered close to 7 million Naira in Bauchi amounting to 83% of the total unretired funds.

In the six years of implementation, the MOU has had a tremendous impact on the provision of immunization services in Bauchi state. But the biggest transformation is in the area of transparency and accountability. For instance, an external auditor is now selected together with partners, and the results of the annual audit are published on the SPHCDA website for public scrutiny. Before, the report was only shared with civil society organizations that we were working with.

For any other countries or states that would want to set up a system such as ours, the important thing to do is to identify the gaps and then figure out the steps needed to improve them. Above all, transparency and accountability are key for strong financial management and success of any health program.

This Bright spot story was nominated by Raihanah Ibrahim, a Public Health Specialist who anchors the program implementation, capacity building, and knowledge management aspects of SCIDaR’s immunization work in Nigeria; Idongesit Sampson, a management consultant who works on SCIDaR’s Routine Immunization Program in Northern Nigeria; and Olayinka Dada who led the financial management workstream of the Northern Nigeria Routine Immunization Program. The team has been instrumental in providing technical assistance to the government at National and Subnational levels on program conceptualization, design and implementation.