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.

 

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“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.

 

 

Saving Mothers and Children in Nigeria (Partnerships Series No. 4)

Over their lifetime, one in every 30 women in Nigeria are likely to die due to pregnancy and childbearing. Nigeria alone accounts for one in seven maternal deaths observed in the world today. This post, the fourth in a series on partnerships, innovation, and evaluation in Rotary, tells the story of a project that has succeeded in reducing maternal mortality in Nigeria.

Nigeria saving lives

Project and Partners

Many factors lead to maternal mortality, but a key risk is that of obstetric fistula (a hole in the birth canal). The World Health Organization estimates that each year between 50,000 and 100,000 women suffer from obstetric fistula, which by obstructing labor can lead to maternal death.

Quality assurance mechanisms in hospitals can improve obstetric services and contribute to reducing maternal mortality. This was the premise of a series of Rotary projects aiming to reduce maternal (and fetal) mortality in Nigeria led by Robert Zinser and the Rotarian Action Group for Population Growth and Development (RFPD) between 2005 and 2010.

With support from RFPD and some 200 Rotary, Rotaract and Inner Wheel Clubs, Rotary implemented a first project to improve quality assurance mechanisms in ten hospitals in Kano and Kaduna States in Northern Nigeria. Apart from funding from Rotary clubs and the Rotary Foundation, support was also provided by the German Ministry for Economic Cooperation and Development (BMZ), the Aventis Foundation and the International Association for Maternal and Neonatal Health (IAMANEH). The project was implemented by Nigerian Rotarians.

Innovative Approach

Conceptually, reducing maternal and fetal morbidity and mortality can be achieved through an improvement in the quality of the infrastructure and other inputs used to provide treatment (availability of medicine, better hospital facilities, etc.) as well as improvements in the process of providing treatment (more experienced health personnel). The project team worked on both fronts.

In terms of improvements in infrastructure, a number of investments were made, including two specialized fistula wards (one for each of the two Nigerian states) with rehabilitation facilities. Medical equipment was provided to ten hospitals and some hospitals were equipped with better water supply and solar energy. Hospitals also received intrauterine devices for women requesting them for family planning as well as drugs preventing mother-to-child transmission of HIV.

To improve the capacity of hospital personnel, seven doctors were trained as fistula surgeons and 15 ward nurses were trained in fistula care. Many more doctors, nurses and midwives, and other health personnel such as traditional birth attendants were also trained on how to improve obstetric services. Hospital teams were trained in emergency obstetric care including (among others) in the use of magnesium sulfate to manage eclampsia and the use of an anti-shock garment to treat postpartum hemorrhage.

Apart from providing support to the hospitals participating in the project, support was also given to communities in the hospitals’ catchment areas. Mosquito nets were provided to reduce the risk of contracting malaria. Awareness and advocacy campaigns were held using radio, television, print media, and even drama (public plays on the streets) to inform the population about obstetric fistula, its causes and how to prevent it, and its impact on maternal and fetal mortality. These awareness campaigns enlisted the support of traditional and religious leaders who have substantial influence on behaviors in the community.

Perhaps the most important innovation was the development of a quality assurance mechanism that involved setting standards and systematically collecting data on the quality of the care being provided and the outcomes in terms of maternal and fetal mortality and morbidity. This was done through a “quality circle” process to monitor, review, and improve performance over time. Data were collected in participating hospitals, analyzed statistically, discussed by the teams, and used to assess improvements and take corrective measures as needed.

Evaluation

An evaluation based on the data collected by the hospitals as part of the quality assurance mechanism before, during and after the intervention suggests that the project achieved a 60 percent reduction in maternal mortality in participating hospitals and 15 percent reduction of newborn mortality.

Conclusion

RFPD’s obstetric fistula project combines all three ingredients of a winning combination for impact: partnerships, innovation, and evaluation.

The team established multiple partnerships for funding (the investment for the pilot project in the ten hospitals amounted to one million Euros) and implementation (securing buy-in from the hospitals, the state authorities, the communities, and even traditional and religious leaders).

The project included innovative components in the Nigerian context, especially the quality assurance mechanism and data collection process to improve the quality of obstetric care.

The project was evaluated using data from the quality assurance mechanism and the evaluation was published in an academic journal.

The project has been considered a success by stakeholders and the Kano and Kaduna state governments. This led to a subsequent project to continue to build capacity in the original 10 participating hospitals, and extend the model to 15 more hospitals (five rural hospitals in FCT Abuja, five hospitals in Ondo State, and five more in Enugu State). Additional scaling up is being considered by the RFPD team.

A brief on the project and the Nigerian context is available here.

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/.

Polio Eradication: A Priority Investment?

by Quentin Wodon
Today is world polio day, the ideal day to launch “Rotarian Economist”. This blog will feature commentary and analysis to support Rotarians in their “service above self” mission. Given that polio eradication is a priority for Rotary International,  this first blog is about polio.

Polio image

Reports earlier this year have documented a polio outbreak. The wild poliovirus has spread in central Asia (from Pakistan to Afghanistan), in the Middle East (from the Syrian Arab Republic to Iraq) and in Central Africa (Cameroon to Equatorial Guinea). In May the World Health Organization declared that the spread of the virus constitutes an “extraordinary event”. The situation is most serious in Pakistan where most of the cases of paralysis observed to date for 2014 have been recorded.

Polio is preventable through vaccines. Yet polio eradication is at risk. The WHO Emergency Committee unanimously concurred that conditions for a Public Health Emergency of International Concern had been met, recommending among others to vaccinate all those traveling outside affected countries. While three in four people carrying the virus have no symptoms, they can all be highly contagious.

Polio used to be a devastating disease affecting 30,000 children per year in the United States alone in the mid 1950s. Thanks to vaccines and mass immunization campaigns reaching more than 2.5 billion children over the last 15 years, the number of polio cases worldwide has dropped to close to zero. But it is essential to reach the last mile. Unfortunately vaccination remains difficult in many conflict affected areas, and the risk of exportation of the virus from those areas to other countries is real.

The dramatic reduction in polio cases in the last fifty years has been a great success built on strong public-private partnerships. While many governments have funded the polio eradication campaigns, after the United States (with $2.2 billion in contributions and pledges) the two largest donors from 1985 to 2014 have been private foundations – the Bill and Melinda Gates Foundation ($1.9 billion) and Rotary International ($1.3 billion). Apart from financial donations, hundreds of thousands of volunteers – including many Rotarians from all over the world – have participated in polio vaccination campaigns.

In a February 2014 report, UNICEF and WHO estimated the price tag for polio eradication for the period 2013-18 at $5.5 billion. The available contributions amount to $1.8 billion, but the remaining funding gap is at $3.7 billion. Private partners such as the Bill and Melinda Gates Foundation and Rotary International are stepping up to the plate. But more needs to be done by donors and multilateral organizations.

As a Rotarian, I used to wonder whether it made sense to spend that much money on a disease that seemed to affect only a few children. But the available research suggests it does, not only from an ethical point of view but also from an economic or investment point of view. This is because the cost of a spreading virus could be much higher.

Another report for the Bill and Melinda Gates Foundation suggests that previous investments of $9 billion since the creation in 1984 of the Global Polio Eradication Initiative (GPEI) may have already generated $27 billion in net benefits out of $40-50 billion in potential benefits estimated by researchers in an economic analysis of the GPEI. While investments in polio eradication campaigns have higher initial costs than routine immunization, they have much greater long term payoffs.

In the case of polio eradication as in many other cases of investments in young children, investing what is required is not only the right thing to do: it is also the smart thing to do.