Financing Polio Eradication and Development in Nigeria’s North-East

New cases of polio have emerged in Nigeria. Ahead of World Polio Day, readers of this blog should know that Rotary and other international organizations are stepping up to the plate. In September 2016, Rotary committed an additional $35 million to end polio, bringing its contribution to $105 million in 2016. Two months earlier, the World Bank approved in June 2016 $575 million in additional IDA financing for Nigeria to scale up support for the North-East of the country. This includes $125 million for polio eradication over three years (2017-2019).

polio-nigeria

The World Bank program document for the additional polio financing notes that multiple obstacles remain to eradicating polio in Nigeria due to a lack of accessibility of some communities in the Northern States. This has led to special measures being introduced, including “(a) ‘hit and run’ interventions where vaccinators use any opportunity to go to difficult areas with the military and leave as soon as all children have been reached; (b)‘fire-walling’ that is, ensuring immunity in areas surrounding inaccessible villages; (c) using local people as vaccinators who can operate without drawing attention; (d) including IPV (Inactivated Polio Vaccine) in routine immunizations activities; (e) having transit bus-stop and market vaccination teams; and (f) ensuring that all internally displaced people residing in camps are covered.”

Despite these efforts, immunization coverage for polio and other vaccines in the North-East still lags far behind the national average. The $125 million additional financing for polio has two components.

  • The first component provides $60 million for  Oral Polio Vaccine (OPV) and other operational requirements of polio eradication activities. UNICEF will receive $50 million to procure OPV. The additional US$10 million will be used by UNICEF or WHO for a range of activities where funding gaps may be identified, including activities for Immunization Plus Days.
  • The second component ($65 million) will help finance routine immunization. The inclusion of a component on routine immunization stems from the fact that it has been shown to be essential for interrupting the transmission of wild polio and thereby completing polio eradication, while also being a critical aspect of improving child and maternal health.

The program document for the additional polio financing is available here.

The difficulties in eradicating polio in the North-East are related in part to insecurity and a broader lack of services and development opportunities. The Boko Haram insurgency has deeply affected the states of Borno, Yobe, Adamawa, Taraba, Bauchi and Gombe, with negative impacts on an estimated 15 million people.

As per the press release for the additional financing package for the North-East, the other components of the package include:

  • $75 million for the Nigeria Community and Social Development Project which provides immediate basic social infrastructure and psychosocial support to communities most affected by displacement;
  • $100 million for the Youth Employment and Social Support Operation to provide youth, women and the unemployed (especially internally displaced persons, returnees and persons with disabilities resulting from the crisis) with labor-intensive work and skills development opportunities. Cash transfers will also be provided to displaced families and individuals as they return voluntarily and safely to and settle in their old or new communities.
  • $50 million for the Third Fadama Development Project that  addresses the emergency needs of farmers by improving access to irrigation and drainage services, delivery of agricultural inputs, and contributing to the restoration of livelihoods in conflict-affected households with a focus on women and youth.
  • $100 million for the State Education Program Investment Project that supports the return to teaching and learning through financial incentives for teachers who have completed psycho-social training, and provide grants to schools to address their needs as identified by school-based management committees.
  • $125 million for the National State Health Investment Project (plus $20 million from the Global Financing Facility) that will help to reestablish health services with a focus on maternal, newborn and child health, nutrition, psycho-social support and mental health. In communities in which health facilities have been destroyed, mobile clinics will be deployed to provide care.

As Rachid Benmessaoud, the World Bank Country Director for Nigeria explained it,  “The needs are staggering. Millions of people have lost their livelihoods, schools and health facilities have been destroyed, and the psychosocial impact of the crisis must also be addressed. To help create economic opportunities for the most vulnerable, we have identified a set of initiatives that will have a quick and tangible impact on the population in four priority areas: agriculture, education, health and social protection.

The World Bank press release on which this blog post is based is available here together with links to other related resources.

Polio Immunization in Yemen

A few months ago, I shared news through this blog about the approval of a new World Bank project for routine immunizations in Pakistan which included a component on polio.  Rotarian friends mentioned to me at the time that my blog post did not mention Rotary. The reason was that the project included partnerships with organizations such as the Bill and Melinda Gates Foundation, but not Rotary International. This was because the project did not focus solely on polio even though it included a component about polio, and Rotary (legitimately) targets its limited financial resources to projects focusing on polio only.  Beyond Pakistan, quite a bit is being done in developing countries on polio through routine immunizations. As Rotarians we should be aware of this.

Yemen 2016-Jul-6-feature-cover
Cover photo: Ashwak Althabibi holding her eight-month-old son Najran, who was vaccinated as part of the campaign. Photo credit: UNICEF.

Yesterday I came across a story about another World Bank project that included a polio component in Yemen.  As this may be of interest to some Rotarians, let me share this hopeful story below, which includes links to the project appraisal document (for those who like details, this document explains how the project works). A key message from the story is that by partnering with UNICEF and WHO, the World Bank was able to maintain disbursements for this project despite the conflict situation in the country.  As a result, the project has provided critical support for the national polio campaign which has managed to vaccinate 1.5 million Yemeni children despite the conflict.

 

______________

“This is so critical to us. We cannot afford to lose another child!” With these words, Ashwak Althabibi, a 36-year-old mother of six children, shared the story of losing her daughter Nora last year.

“We couldn’t get her to the hospital soon enough, and by the time we found a transportation and reached the hospital, Nora was gone,” Althabibi added with tearful eyes. She composed herself to say “I just want to thank the vaccination team for their perseverance. They come on a regular basis and vaccinate all my children. It’s a great consolation for us to feel such care.”

“No transportation can get there and it is the team’s responsibility to reach this population and to make sure all their children get vaccinated during this hard time,” commented Hana Ali Nagi, a 19-year-old health volunteer in the vaccination campaign.

Since the start of the current conflict, Yemen suffered massive damage to infrastructure, such as hospitals and clinics, and the interruption of medical supplies. Many foreign health personnel have left, and even the most basic needs for a healthy existence—access to water, sanitation, and food—have become, for most Yemenis, a daunting, daily task.

Gone too are the days when the victims of war were mostly soldiers: the Yemeni conflict has been unfair to women and children, which means the most vulnerable Yemenis are bearing the brunt of the conflict.

Thousands of Yemeni children have been killed and injured in the war, and hundreds of thousands put at more risk of death from disease or malnutrition. The UN’s Children’s Fund (UNICEF) estimates that 320,000 children now face severe malnutrition, while 2.2 million need humanitarian aid urgently to prevent their nutritional status from deteriorating.

The last two decades have been a prolonged period of political instability and economic fragility in Yemen, a country with both limited natural resources and an underdeveloped institutional capacity for project implementation.

But one lesson from previous World Bank Group experience in the health sector is that government ownership, simple project design, and donor coordination should come top of the list of the ways to make things work.

Yemen’s Health and Population Project (HPP) has a simple, evidence-based outreach delivery model for health services in coordination with UNICEF and the World Health Organization (WHO), in order to procure some of the essential medications and medical supplies needed for the outreach campaigns.

This has enabled the Bank to continue its support to the project, when the war escalated and the Bank’s whole portfolio in Yemen was suspended, through channeling grants from the International Development Association (IDA – the World Bank’s fund for the world’s poorest countries) directly to UNICEF and WHO to deliver vaccinations and basic health services such as nutrition and reproductive health to children and women, respectively.

Since the project’s activities resumed in January 2016, around 1.5 million Yemeni children under five years old were reached by the national polio campaigns supported by the project, which represents about 30 percent of the whole target population nationwide.

“Conflict can have devastating, multi-generational impacts, but by leveraging our partnerships in Yemen we are able to continue investing in children’s health, which is a vital investment in the country’s future,” said Asad Alam, World Bank country director for Egypt, Yemen and Djibouti.

The outreach model aims to reach children in the places where they are living, often in remote areas that are hard to get to. It will continue to operate like this until the foundations of the country’s public health system are back in place. Simple, ready-to-go interventions are what Yemenis want to see as a practical response to their desperate need for basic health care. Health workers use different ways to deliver those services in such remote areas where camels, donkeys, or mountain climbing are usual means of transportation.

More outreach rounds for basic health services are planned, although the security situation prevents access to children in some areas. But overall, because of the problems of damaged infrastructure, fuel shortages, displacement and increased poverty, the simple outreach model of delivering basic health services is best suited to Yemen’s present situation. A door-to-door health round gives children the chance of getting vaccinated at home, with health professionals and volunteers spreading out across the country, mobilizing communities and vaccinating children.

Hopefully, soon peace will mark a new chapter, both in rebuilding Yemen and its health system, and improving the lives of all Yemenis and particularly its future, the children.

Thanks go to UNICEF for sharing real stories and photos from the field.

This story is reproduced from the World Bank website.

 

 

Buying Down Polio (Partnerships Series No. 2)

By partnering with the World Bank in an innovative way, Rotary has successfully leveraged  its funding for polio eradication, contributing to success towards one year without polio in Nigeria and in Africa. This post, the second in a series on partnerships, innovation, and evaluation, explains how the innovative polio buy-down mechanism has worked.

PIC 3. FROM LEFT: PRESIDENT MUHAMMADU BUHARI VACCINATING HIS THREE MONTHS OLD GRAND-DAUGHTER, ZULEIHA BELLO ABUBAKAR WITH ORAL POLIO VACCINE TO MARK ONE YEAR OF FREE POLIO CASE IN NIGERIA AT THE PRESIDENTIAL VILLA ABUJA ON SATURDAY (25/7/15). WITH HIM ARE: EXECUTIVE DIRECTOR, NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY (NPHCDA) DR ADO MUHAMMAD AND THE INCIDENT MANAGER, POLIO EMERGENCY OPERATION ABUJA CENTRE, DR ANDREW ETSANO 028/JULY2015/ICE/STATE-HOUSE
Nigeria’s President vaccinates his granddaughter – Photo courtesy of Dr. Etsano.

Last month, Africa achieved a key milestone towards polio eradication, with no case of polio observed for a full year. It will still take a few weeks for the World Health Organization to officially certify this milestone, and for the region to be declared polio-free, no polio cases should be observed for a period of three years. Still, tremendous progress towards polio eradication has been accomplished. Just a few years ago, hundreds of cases of polio were observed annually in Nigeria. The country achieved its first full year without polio on July 24, 2015. This will leave only Afghanistan and Pakistan on the list of polio-endemic countries.

As noted in a recent post on the World Bank health blog, achieving one year without polio in Nigeria required persistence and courage. In some areas, professionals and volunteers who led the polio campaigns risked their life: Boko Haram assassinated nine polio vaccinators two years ago in the north of the country. Vaccinators had to rely on “hit and run” tactics to reduce exposure to risk, vaccinating children quickly in the morning and leaving the area by the afternoon. (For an understanding of the role of a wide range of people at the heart of polio eradication (in the case of Afghanistan), see the great slide show provided by the Global Polio Eradication Initiative.)

The polio campaigns also required great effort and creativity from multiple agencies, including through an innovative buy-down mechanism implemented by the World Bank and funded by the Bill and Melinda Gates Foundation, as well as Rotary International and the U.S. Centers for Disease Control via the U.N. Foundation. (The Gates Foundation and Rotary International are the two largest donors worldwide towards polio eradication over the last 30 years.) Partnership with the government of Nigeria, the World Health Organization (WHO), and UNICEF, among others, was also crucial to the success of the campaigns.

How did the polio buy-down mechanism work? The basic idea was for the World Bank to fund polio eradication projects through concessional IDA (International Development Association) loans. In the case of Nigeria, two projects worth $285 million, including additional financing, were implemented over the last dozen years. The projects included clauses that allowed loans to Nigeria to become grants if the country achieved a high level of polio immunization coverage. In other words, if the immunization targets indicated in the loans were achieved and verified independently through in-depth audits, the government would receive grant funding for polio eradication without the need to repay the loans.

For the government of Nigeria, this was potentially a great deal. And for the Gates Foundation and the Rotary Foundation of Rotary International, this was also a pretty good investment. In general, investments towards polio eradication have been shown to be fairly cost-effective. But with the buy-down mechanism, these investments were especially cost-effective.

Due to the concessional nature of IDA loans (long-term zero or low-interest loans which grace repayment periods), for every dollar contributed to the buy-down, the actual amount of resources that could be transferred to the government for the polio campaigns was two times larger. The buy-down funds were transferred by the Gates Foundation and Rotary International (in the case of Rotary in partnership with the United Nations Foundation) to the World Bank at the start of the project, and used to repay the loan at the end of the project if the target immunization rates had been achieved.

Through this buy-down mechanism, the Gates Foundation and Rotary International were able to offset all future loan repayment obligations with a much smaller amount of funding to pay back IDA than the face value of the loans granted to Nigeria. Again, one dollar invested by these private donors generated about $2 for polio eradication in Nigeria, with a similar mechanism in place for Pakistan. The mechanism also had built-in incentives to encourage strong implementation performance by the government of Nigeria since the loans would be transformed into grants only if the specific immunization targets were to be achieved.

At the time of the first buy-down mechanism for polio, then-World Bank President James. D. Wolfensohn stated, “The partnership to buy-down loans to grants on the basis of good performance is an example of the innovative thinking occurring in the private sector and the World Bank about how to increase finances for the fight against global diseases. This financial innovation is bringing the goal of a polio-free world one large step closer to becoming reality.”

Could similar buy-down mechanisms be applied in other areas? That was probably the hope when this innovative mechanism was created for polio a dozen years ago. It seems however that with few exceptions the idea has not yet been replicated much in other development areas, even if it has been mentioned in a number of reports, including in a Results for Development report on education.

A number of conditions have to be met for this type of buy-down mechanism to be successful. But in the case of polio, it has been successful, enabling the Gates Foundations, individual Rotarian donors through the Rotary Foundation, the United Nations Foundation, and the World Bank to achieve higher impact towards polio eradication than would have been the case otherwise.

A brief on polio in Africa and the buy-down mechanism is available here.

This post is reproduced with minor changes from a post published by the author on September 2, 2015 on the World Bank’s Financing for Development blog at http://www.fin4dev.org/.

Technology in Nepal’s classrooms: Using impact evaluation as a learning device

Students use laptops and digital resources provided by OLE Nepal
Students use laptops and digital resources provided by OLE Nepal

Impact evaluations are becoming essential in the way we think about development and service projects. Pilot programs suggesting statistically significant impacts are hailed as breakthroughs and as candidates for scaling up. Programs without such clear impact tend to be looked down upon and may be terminated. This may not be warranted. A primary function of impact evaluations should be to improve existing programs, especially in fields where evidence of positive impacts remains scarce. The experience of OLE Nepal, which is part of the OLE network and aims to improve learning and teaching through technology, is instructive in this regard.

Last week, Rabi Karmacharya shared his experience at OLE Nepal at a seminar co-sponsored by the World Bank, the Global Partnership for Education and the Rotary Club of Capitol Hill, a supporter of Rotary Club of Kathmandu Mid Town in expanding OLE Nepal’s programs. After a successful career in engineering and technology in California, he launched OLE Nepal in 2007. Now a social entrepreneur, Rabi wants to use technology to transform the way children learn through engagement, exploration and experimentation.

OLE Nepal has achieved quite a bit over the last eight years: deploying 5,000+ laptops in 100+ schools, training 600+ teachers on integrating ICT in the classroom teaching-learning process, developing 600+ learning modules for use by teachers, and creating a digital library with 6000+ books and other items used in schools and community libraries. Its ultimate objective is to help transform and improve Nepal’s education system with technology, working closely with the Ministry of Education and other partners.

What I found most interesting about Rabi’s presentation is how OLE Nepal – as well as donors that support the NGO such as the World Food Program, responded to an evaluation of its programs in 2009-11. The evaluation used a quasi-experimental design: English and mathematics tests administered to students, with collection of additional data through student, teacher and household surveys.

The results were disappointing, with no effect on student test scores even though both teachers and students reported liking the digital contents and finding them useful. The results contradicted field observations and other evidence from teachers and students on the fact that the program was making a difference.

Several factors may have led to an apparent lack of impact on student learning, according to Rabi. First, the program had been implemented only for a relatively short period of time, and improving student learning takes time. Second, it turned out that not all teachers reported to the one-week intensive training session that was held before launching the program, which may have decreased overall impacts in the schools that benefitted from the program. Third, some teachers may not have used as the available digital resources as much as expected due to the increase in workload that this entailed. Fourth, after the initial training, the support provided to teachers was limited. Fifth, it could be that the digital content, while following the curriculum taught in school, was too difficult for students to grasp.

These and a number of factors (including questions about variations in exam difficulty between the baseline and endline tests in the evaluation, and the possibility that some students spent more time on games available through the digital libraries rather than on study for examinations) may have led to the results.

What is important is that the evaluation did not lead to the demise of the program. Witnessing firsthand the changes in classroom dynamic and student engagement brought about by the program, donors continued to fund the NGO, which has been able to grow with support from the World Food Program, the Embassies of Denmark and Finland, and most recently the Air Asia Foundation.

In response to the evaluation, OLE Nepal introduced a number improvements in its programs:

  • It now promotes a shared model between grades for a more effective use of laptops and digital resources by schools and teachers;
  • The use of resources by students is better supervised and teachers receive more extensive support after the initial one-week training. In addition, a volunteers program is available for additional support;
  • The educational contents have been revised to follow the curriculum even more closely; and
  • More emphasis will be put on enhancing the ability of students to read in early grades, since this is a prerequisite for them to be able to learn subsequently and use digital resources effectively.

OLE Nepal’s experience is a great lesson in social entrepreneurship, humility, and resilience from an innovative NGO that strives to help teachers and students harness the power of technology in the classroom.

Note: this post is reproduced with minor changes from a post by the author for the World Bank’s Education for Global Development blog, available at http://blogs.worldbank.org/education/.

Out-of-school Children: A Promise Yet To Be Fulfilled

by Sheena Bell, Friedrich Huebler, and Quentin Wodon

Today, as the Millennium Development Goals draw to a close and the development community is thinking of new development targets, many children are not learning in school. But, in addition, more than 120 million children and young adolescents still remain out of school. That is almost one in ten children of primary school age, and one in seven children of lower secondary school age. For these children, the right to education remains a distant dream.

Perhaps, most alarmingly, data show a steady downturn in the momentum to reach these children. Between 2000 and 2007, substantial gains were made towards universal basic education as tuition fees were abolished, schools were built, and teachers were hired. In absolute numbers, much of the progress achieved in reducing the number of children excluded from school was driven by a small number of countries. In India alone, the number of out-of-school children fell by 16 million between 2000 and 2011, the latest year with available data. Another set of ten countries – Algeria, Burundi, Ghana, the Islamic Republic of Iran, Morocco, Mozambique, Nepal, Pakistan, Yemen and Zambia – were also key contributors. Together, these 11 countries account for more than one-half of the reduction in the global number of out-of-school children since 2000.

But, today, 58 million children between the ages of about 6 and 11 years remain out of school and an additional 63 million adolescents (roughly between the ages of 12 and 15 years) are not enrolled. Since 2007, progress in reducing the global numbers has stopped. As shown in the figure below, the rate of out-of-school children has also remained virtually the same since 2007. Girls, children in poverty, and those living in rural or remote areas are the most affected.

Global out-of-school rate for children of primary & lower secondary school age, 2000-12
Global out-of-school rate for children of primary & lower secondary school age, 2000-12

The latest statistics on out-of-school children are available in a report published in January 2015 by the UNESCO Institute for Statistics (UIS) and UNICEF. While presenting a range of indicators to better identify these children, the report also identifies several barriers to their education. To begin with, one-half of the children out of school live in conflict-affected countries. Gender discrimination continues to be a major factor to the detriment of girls in many countries (although in some countries, especially in the Caribbean, boys lag behind girls). Child labor is also identified as a major problem, while the language of school instruction can be a barrier in many countries, especially for indigenous populations. Children with disabilities continue to be excluded in education systems ill-fitted to meet their needs. All of these factors are exacerbated by poverty. In many countries, low-income households cannot afford the direct costs of sending their children to school (e.g. fees, uniforms or books) or the indirect costs resulting from the lost wages or household contributions of their sons and daughters.

The report is complemented by an innovative data exploration tool that goes beyond the absolute numbers to highlight the critical factors that drive exclusion. In particular, it shows the extent to which factors like gender, location (rural versus urban) and poverty can affect a child’s likelihood to start school late, drop out or even set foot in a classroom. Developed by the UIS, the data tool clearly identifies priorities for any effective policies or interventions to reach these children.

The UIS-UNICEF report provides the most updated information available on out-of-school children globally. It advocates for a combination of supply- and demand-side interventions as well as system-wide policy reforms to help ensure that all children are indeed in school, and calls for a stronger commitment from governments and donors to keep the promise of education for all.

Note: this post was first published on February 23, 2015 on the World Bank Education for Global Development blog.