Understanding Internal Accountability in Nigeria's Routine Immunization System: Perspectives From Government Officials at the National, State, and Local Levels.

Daniel J Erchick,Chizoba Wonodi,Asha S George,Chukwunonso Umeh

doi:10.15171/ijhpm.2016.150

Abstract

Background: Routine immunization coverage in Nigeria has remained low, and studies have identified a lack of accountability as a barrier to high performance in the immunization system. Accountability lies at the heart of various health systems strengthening efforts recently launched in Nigeria, including those related to immunization. Our aim was to understand the views of health officials on the accountability challenges hindering immunization service delivery at various levels of government. Methods: A semi-structured questionnaire was used to interview immunization and primary healthcare (PHC) officials from national, state, local, and health facility levels in Niger State in north central Nigeria. Individuals were selected to represent a range of roles and responsibilities in the immunization system. The questionnaire explored concepts related to internal accountability using a framework that organizes accountability into three axes based upon how they drive change in the health system. Results: Respondents highlighted accountability challenges across multiple components of the immunization system, including vaccine availability, financing, logistics, human resources, and data management. A major focus was the lack of clear roles and responsibilities both within institutions and between levels of government. Delays in funding, especially at lower levels of government, disrupted service delivery. Supervision occurred less frequently than necessary, and the limited decision space of managers prevented problems from being resolved. Motivation was affected by the inability of officials to fulfill their responsibilities. Officials posited numerous suggestions to improve accountability, including clarifying roles and responsibilities, ensuring timely release of funding, and formalizing processes for supervision, problem solving, and data reporting. Conclusion: Weak accountability presents a significant barrier to performance of the routine immunization system and high immunization coverage in Nigeria. As one stakeholder in ensuring the performance of health systems, routine immunization officials reveal critical areas that need to be prioritized if emerging interventions to improve accountability in routine immunization are to have an effect.

Highlights

Routine immunization coverage in Nigeria has fluctuated in recent years, with only 38% of children reached with three doses of the DPT3/Penta[3] vaccine (Nigeria Demographic and Health Survey [DHS] 2013); this compares to 68% in neighboring Cameroon (DHS 2011), and 89% in nearby, high-performing Ghana (DHS 2014).[16,17,18]
Delivery of immunization is the responsibility of the State Ministry of Health and State Primary Healthcare Development Agency, and occurs at most of the state’s 1322 public and privately owned primary healthcare (PHC) centers, 12 secondary facilities, and a single tertiary facility, the majority of the burden falls to PHC centers, which are often understaffed and underequipped.[30]
Weak accountability presents a significant barrier to performance of the routine immunization system and high immunization coverage in Nigeria

Summary

Introduction

Interest in accountability in health is rapidly rising, with several reviews recently published,[1,2,3,4,5] multiple donor and civil society networks organized,[6,7] research initiatives underway,[8] and a global strategy for women’s, children’s, and adolescent’s health, with a strong focus on accountability, launched in 2010 by the United Nations Secretary-General.[9,10] Most efforts to address accountability in health systems have focused on external accountability, ie, how communities interact with the system to improve responsiveness.[7,11,12] However, internal accountability, which involves the interactions of technical, managerial, and political actors within government, is of equal importance, and plays a foundational role in the quality of healthcare services.[3,13,14] In Nigeria, accountability is also a concern for health services, including immunization.[12,15] Routine immunization coverage in Nigeria has fluctuated in recent years, with only 38% of children reached with three doses of the DPT3/Penta[3] vaccine (Nigeria Demographic and Health Survey [DHS] 2013); this compares to 68% in neighboring Cameroon (DHS 2011), and 89% in nearby, high-performing Ghana (DHS 2014).[16,17,18] There is significant heterogeneity in the strength of routine immunization systems among Nigerian states, and studies have attributed poor performance to accountability challenges crosscutting governance, service delivery, finance, human resources, logistics, and data management.[19,20,21,22] Nigeria has a decentralized healthcare system, with responsibility for tertiary, secondary, and primary healthcare (PHC) assigned to the federal, state, and local levels, respectively. Management of the delivery of primary healthcare services, including immunization, falls to local governments, which typically have the least resources and capacity.[23] State

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Discussion

Conclusion