Journal of Community Medicine & Public Health (ISSN: 2577-2228)

research article

  PDF Download

“Campaign Staggering” a Way to Bridge Resources Gaps in Supplemental Immunization Activities-Lagos State 2018 Measles Vaccination Campaign’s Experience

Chimaobi Ihebuzor 2# , Avuwa Joseph Oteri 1*# , Samuel Bawa 3 , Adejoke Oladele Kolawole 2 , Boubacar Dieng 4 , Anne Eudes Jean Baptiste 3 ,  Bolanle Orefejo 5 , Nneka Onwu 2

1 Nigeria Governors Forum, Abuja, Nigeria

2 National Primary Health Care Development Agency, Abuja, Nigeria

3 World Health Organization, Country Office, Abuja, Nigeria

4 Technical Assistance Consultant, Gavi, The Vaccine Alliance, Nigeria

5 UNICEF, Lagos Field Office, Nigeria

# These authors contributed equally to this work

*Corresponding author: Avuwa Joseph Oteri, Nigeria Governors Forum, Abuja, Nigeria

Received Date: 15 November, 2022

Accepted Date: 24 November, 2022

Published Date: 29 November, 2022

Citation: Ihebuzor C, Oteri AJ, Bawa S, Kolawole AO, Dieng B, et al. (2022) “Campaign Staggering” a Way to Bridge Resources Gaps in Supplemental Immunization Activities-Lagos State 2018 Measles Vaccination Campaign’s Experience. J Community Med Public Health 6: 270. DOI: https://doi.org/10.29011/2577-2228.100270

Abstract

Introduction: The availability of qualified Health Workers (HW) and Cold Chain Equipment (CCE) has been one of the major challenges faced in all countries implementing Supplemental Immunization Activities (SIAs) including Nigeria. This challenge has been found to contribute to the country’s inability to reach the set targets. This paper describes how Lagos state staggered its 2018 measles vaccination campaign to mitigate the resources gaps of health workers and cold chain equipment. It also highlights the effectiveness of staggering as it relates to campaign outcome, looking at the number of children reached during the campaign. Methods: The microplanning process was followed by a 2 (two) step verification of the states micro-plans. These processes helped Lagos state to identify gaps in qualified health workers and CCEs. Data was analyzed and presented using MS Excel and Statistical Package for Social Sciences version 20 (SPSS). Results: Findings showed inadequate health workers and CCEs across all LGAs in the state to implement the SIAs at the same time. A total of 8,948 health workers were required to reach the target population. For CCEs a total of 752 cold boxes, 9050 vaccine carriers, and 90,448 ice packs (0.3/0.4 & 0.6) were required. However, only 3,769 health workers, 640 cold boxes, 4985 vaccine carriers, and 56,971 icepacks (CCEs) were available for the 2018 MVC in the state. This left a gap of 44 cold boxes, 4065 vaccine carriers and 33477 ice-packs. Following the staggering of the campaign where the measles vaccination campaign was implemented in phases (phase 1 and phase 2), the shortfall was reduced. The outcome of the campaign in terms of the number of targeted children reached when compared to previous measles vaccination shows modest improvement. Conclusion: The staggering approach introduced by the National Measles Technical Coordinating Committee during the 2017/2018 measles vaccination campaign helped Lagos state in reducing the gap in required qualified health workers and CCE needed for a quality vaccination campaign. In the same vein, more children were reached in the 2018 measles vaccination campaign when compared to previous campaigns.

Keywords: Supplemental immunization activities; Staggering; Qualified health workers; Cold chain equipment

Introduction

The United Nations Sustainable Development Goals (SDGs), also known as Global goals were countries’ commitments toward the ending hunger, protecting the planet, and ensuring that by 2030 all people enjoy peace and prosperity. Reduction of measles mortality will contribute to the attainment of SDG3 which aims to end preventable deaths of newborns and children under 5 with all countries striving to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births amongst other indicators by 2030 [1,2].

Measles is one of the key contributors to child mortalities, especially in South Asia and Sub Saharan Africa [3]. The measles vaccine was among the antigens introduced in Nigeria’s Expanded Program on Immunization (EPI) schedule in 1979, and it is administered to children 9 months of age. Since then, coverage of the first dose of Measles Containing Vaccine (MCV1) through the routine immunization program has been fluctuating and also very suboptimal to provide the needed herd immunity to prevent its transmission among children [4].

The World Health Organization and United Nations Children Fund Estimates of National Immunization Coverage (WUENIC) for Nigeria from 2009 to 2017 for MCV1 coverage averaged 49.4% [5]. The National Immunization Cluster Survey (NICS) of 2016 - 2017 coverage for MCV1 prior to the 2017/2018 measles vaccination campaign was 42%. However, variation exists across zones and states with Lagos state having an average coverage of 88% in the 2016 - 2017 NICS [6]. It is worth noting that at the time the 2017/2018 measles vaccination campaign was carried out in Nigeria; was yet to introduce a measles second dose in her routine immunization schedule. Measles second dose has been shown to improve seroconversion for children, which ultimately takes care of primary vaccine failure [7]. The SIA that targeted a wider age group (9-59 months) offered the second dose opportunity to reduce the buildup of susceptible due to poor routine and primary vaccine failure.

As previously mentioned, persistently low MCV1 coverage and relatively low SIAs coverages in the measles follow-up campaigns (74% in 2013 and 84.5% in 2015) have resulted in a low population immunity profile that has allowed increased transmission of measles virus among children. The low immunity profile was the basis for the 2017/2018 nationwide measles mass vaccination campaign. Also of note is that as of 2017/2018 measles vaccination campaign, Nigeria had not introduced the measles second dose into her routine immunization schedule missing the opportunity of increasing the immunity of the children against the measles virus.

Nigeria adopted the WHO African Regional office 2011 measles elimination goal by the year 2020. One of the major targets in achieving the 2020 goal is the attainment of ≥ 95% coverage in MCV1 at National and subnational levels in both routine immunization and supplemental immunization activities. The approach comprised four key strategies of Supplemental Immunization Activities (SIAs) in the form of catch-up campaigns and follow-up campaigns, case-based surveillance for measles, and routine immunization as the core strategy. Measles outbreak response, measles case based management and vitamin A supplementation were also integrated into the key strategies [8,9].

The 2005/2006 nationwide catch-up campaign targeted 56 million eligible children aged 9 months through 14 years irrespective of vaccination status. This campaign was implemented in two phases; phase one covered the Northern states and was conducted in December 2005, while the second phase involving the Southern states was conducted in October 2006. Since then, Nigeria conducts nationwide follow-up campaigns every two or three years. All the country’s measles vaccination campaigns have adopted the same approach of implementing campaigns in two phases with states in each phase implementing the campaign across all Local Government Areas (LGAs) in the state at once irrespective of available resources.

Lessons learned from those SIAs have shown that implementing campaigns using this strategy did not achieve the desired goals as the teams are usually overstretched within the stipulated days thereby missing some of the targeted population. To implement a quality SIA, adequate human and materials resources – skilled health workers and Cold Chain Equipment (CCE) – are needed. The sub-optimal performance in the previous campaign was attributed to shortage of skilled health workers and inadequate CCEs [10].

To bridge this gap the country introduced innovative strategies in the 2017/18 MVC to improve the performance of states. One of these strategies was changing the two-phase National approach and increasing the number of streams of the campaign to regional levels [11]. At the state level, a staggering approach of the vaccination campaign was adopted in some states to take care of the resources gaps.

Staggering simply refers to the arrangement of events or activities to commence at different times. Staggering of the campaign was necessitated based on the available qualified health workers, cold chain available for implementation as well as human resources for monitoring and supervision of the campaign. Since the 2005/2006 catch-up campaign and the subsequent follow-up campaigns, the 2017/2018 follow-up campaign was the first that staggering was introduced at the state level.

This article describes how Lagos state staggered the implementation of the 2018 measles vaccination campaign and the impact it had on reaching more of the targeted children in the state. We also highlighted the effectiveness of this staggering approach by analyzing previous measles vaccination campaign results and that of the 2018 measles vaccination campaign that was staggered to fill resources gaps.

Methods

Study Setting

Lagos state is the commercial capital of Nigeria, and it is located in the southwestern part of the country. It shares boundaries with Ogun state at the North-East border, Benin Republic in the west, and the Atlantic Ocean in the South. It is a highly commercial town, it has a small landmass but has the highest urban population in Nigeria. Movement in and out of the city is constant as people live in the neighboring Ogun state yet work in Lagos state. Visitors from all over West Africa visit the states because of its commercial activities. According to the National Population Commission, in 2017 Lagos state had a projected population of 12,615,361 people [12]. The state targeted a total of 3,660,480 children 9 months to 59 months for the campaign.

2017/2018 Measles Vaccination Campaign

Microplanning Process

Immunization services be it routine services or the supplemental immunization activities requires a lot of planning to know the available resources – human, financial, storage space, as well as the demographic statistics of the recipients. For cost effectiveness of immunization, one must know the target population [13,14]. Microplanning is a bottom-up process of estimating the resources (human and material) needed for the successful implementation of any activity. The output of any SIA microplanning process should include the requirement and availability for data tools, qualified personnel and functional CCE to reach the target population. The micro plan document will identify the required, available and surplus or gaps of these resources at all levels for proper planning.

The micro-planning process in each ward was facilitated by a Ward Focal Person (WFP) in collaboration with all key stakeholders at the operational level. Micro plans were developed by all 245 implementing wards in the 20 LGAs in Lagos state to ascertain the number of children in the target population to be reached, and human, material and financial requirements for the campaign. Other outputs of the process include the list of settlements, health facilities, special places, Daily Implementation Plans (DIPs) including team movement to special places and settlements without vaccination posts., number of vaccination teams, number of vaccination posts, waste management plans. Identification and selection of vaccination posts is one of the key outputs of the microplanning process and it contributes to the success of the SIAs in general. The major aim of using vaccination posts is to ensure there is a conducive and easily accessible place for the vaccination exercise to take place. According to the 2017/2018 NPSIAs field guide, vaccination posts should be ≤ 1KM from the client. Some other key factors to consider when selecting a site to serve as a vaccination post are each settlement should have a vaccination post, shelter, free flow of clients and health workers. Vaccination posts are either fixed posts or temporary fixed posts. Fixed posts are posts where vaccination exercise will implemented for the entire duration of the campaign. Temporary fixed posts are vaccination posts were vaccinations would take place for a period depending on the target population in the catchment area.

To ensure good quality of the exercise, supervision was undertaken by the state/LGA teams using a paper-based checklist and Open Data Kit (ODK).

Micro-Plan Phase 1 Verification

Following the development of the micro-plans, the next step was the verification process, which was implemented in 2 phases for the micro-plans developed. Micro plan verification is an endprocess activity conducted in 2 phases after micro-plan data has been collated at the state level. Phase 1 of the verification is done at the ward level by the LGA and state verification team comprising government and partners. A random selection of 30% of the wards was conducted for the micro plan phase 1 verification process and all LGAs encompassing these wards were directly assessed by the state verification team comprising the state Government and partners present [15].

Micro-plan Phase 2 Verification

The standard micro-plan phase 2 verification process for the measles SIA required that after reviewing the phase 1 verified micro-plan at the National level, a team of two members of the National Measles Technical Coordinating Committee (NMTCC) is deployed to the state for phase 2 verification purposes and joint decision making on how to resolve the identified issues. Among those issues was deciding how the implementation will be handled by not doing business as usual. The phase 2 verification process used the WHO measles high-risk assessment tool correlated with the state findings during the phase 1 verification process in terms of challenges for choosing the two LGAs where to verify and the four facilities by LGA to go to and complete the process. The phase 2 verification process involves three stages [1] desk review of the microplanning templates, [2] field visit and [3] debriefing of the state policymakers [15]. Epe LGA and Surulere were selected accordingly using the measles high risk assessment tool.

Human resources required for a successful measles follow-up vaccination campaign

According to the 2017/2018 measles vaccination field guide, the estimated workload for a vaccination team is 175 and 125 per day in an urban and rural areas respectively with an average of 150 per team [16].

Cold chain equipment required for a successful measles followup vaccination campaign

The 2017/2018 measles vaccination field guide stipulates the basic minimum cold chain requirement for a successful campaign at the ward and vaccination team level. A ward should have a minimum of 2 cold boxes and each cold box requires 24 0.6 icepacks. For vaccine carriers, each vaccination team requires at least 2 vaccine carriers and 4 icepacks per vaccine carrier [16].

Development of Staggering Plan

Communication for staggering/implementation days

A very robust communication plan contributes to the success of any SIA from the planning to the implementation phase. There were several Advocacy, Communication, Social Mobilization (ACSM) activities implemented during the 2017/2018 measles SIA to sensitize, create demand and increase awareness among the population. During implementation, the town announcer of a vaccination team visited a catchment area on their Daily Implementation Plan (DIP) the evening before the visit of the vaccination team the following day. The visit was to inform clients/caregivers on the place and time of the visit from the vaccination team the following day. This information will also be communicated periodically during the implementation day to support the work of the H2H mobilizers so the staggering date is communicated to them.

National verifiers and the state team reviewed all the LGAs verified microplans for the measles vaccination campaign in the presence of all LGA team members. The microplan template was used to estimate the requirements by the state for the campaign including human resources and CCEs. We estimated the human resource and cold chain equipment required for the campaign in the state using the guidelines of the measles vaccination field guide. We then compared the required human resource and cold chain needs with what was available in the LGAs to identify gaps.

Based on the gaps identified, the LGAs were split into two phases (phase 1 and phase 2) to implement the campaign. LGAs in phase 1 were then paired with LGAs that implemented in phase 2 to support them with their human resources and CCEs to bridge the gaps. Ten LGAs implemented in the first phase while the remaining ten implemented in the second phase.

Quantitative data measure was used to estimate the human resources and cold chain equipment and the vaccination campaign outcome of the 2018 campaign in Lagos State. Data management and analysis were performed using spreadsheets and statistical applications such as MS Excel and Statistical Package for Social Sciences version 20 (SPSS). Simple frequency tables, Cross tabulations, charts and maps were used to present analysis outcomes.

Results

Staggering Plan

Lagos state adopted the inter LGA staggering after the assessment of the available resources (Health workers and CCEs) and the LGAs were paired to support each other during the two phases of the campaign in the state. Table 1 shows the pairing of the LGAs and the implementation days of the measles vaccination campaign. The staggering was discussed at the state level and all the LGA officials were told of the support they are either rendering or receiving from their paired LGAs. Health workers that provided support during the staggering are those licensed to give injection and they worked with the primary owners of the LGA who are conversant with the terrain and developed the daily implementation plans.

Phase 1

Phase 2

April 15 th to 22 nd 2018

April 22 nd to 29 th 2018

Agege

Ifako-Ijaye

Ageromi-Ifelodun

Apapa

Alimosho

Ikeja

Ojo

Badagry

Amuwo-Odofin

Oshodi/Isolo

Mushin

Surulere

Lagos Mainland

Somolu

Ikorodu

Kosofe

Lagos Island

Eti-Osa

Epe

Ibeju Lekki

Table 1: Pairing of LGAs with implementation dates by phases.

Assessment of fast cold chain equipment

Using the 2017/18 MVC operational field guide, we assessed the adequacy of CCEs in the state across all LGAs to implement the campaign. Following the microplanning process, data showed Lagos state had only 640 cold boxes, 4,985 vaccine carriers and 56,971 ice packs. Each cold box is expected to accommodate 24, 0.6-liter ice packs. Each vaccination team should have 2 vaccine carriers with 4, 0.3/0.4litere ice packs in each vaccine carrier leading to an estimated need of 9,050 vaccine carriers. 90, 448 icepacks were needed for the campaign for the cold boxes and vaccine carriers. 752 cold boxes based on a minimum requirement of 2 cold boxes per ward were needed for the campaign with 18,048, (0.6) liter ice packs (Table 2). However, only 640 cold boxes were available leaving a gap of 112 cold boxes. The state required 4,525 vaccination teams with an estimated 9,050 vaccine carriers (two vaccine carriers per team) needed for the campaign. However, only 4,985 vaccine carriers were available in the state leaving a shortfall of 4,065. On ice packs, 56,971 ice packs were available in the state out of the expected 90,448 icepacks needed for the campaign leaving a deficit of 33,477. The available CCEs, requirement and shortfalls are shown in Table 3.

LG As

Target Population

Required

Available

Shortfall

Paired LGA

Available for Paired

LGA

Total Available

Shortfall

After

Pairing

Phase One LGAs

       

Agege

156,862

348

130

218

Ifako –Ijaiye

102

232

116

Ajeromi - Ifelodun

344,868

652

443

209

Apapa

61

504

148

Alimosho

435,421

916

432

484

Ikeja

162

594

322

Ojo

398,129

958

319

639

Badagry

185

504

454

Amuwo – Odofin

98,151

264

161

103

Oshodi/Isolo

360

521

-257

Mushin

284,263

616

300

316

Surulere

100

400

216

Lagos Mainland

110,452

296

120

176

Somolu

151

271

25

Ikorodu

381,129

716

215

501

Kosofe

85

300

416

Lagos Island

55,868

200

79

121

Eti- Osa

95

174

26

Epe

33,524

208

140

68

Ibeju Lekki

87

227

-19

Phase Two LGAs

       

Ifako –Ijaiye

148,781

456

102

354

Agege

130

232

224

Apapa

51,443

160

61

99

Ajeromi - Ifelodun

443

504

-344

Ikeja

115,962

316

162

154

Alimosho

432

594

-278

Badagry

201,649

464

185

279

Ojo

319

504

-40

Oshodi/Isolo

321,084

718

360

358

Amuwo – Odofin

161

521

197

Surulere

165,492

526

100

426

Mushin

300

400

126

Somolu

132,456

364

151

213

Lagos Mainland

120

271

93

Kosofe

120,824

360

85

275

Ikorodu

215

300

60

Eti- Osa

74,557

204

95

109

Lagos Island

79

174

30

Ibeju Lekki

29,565

206

87

119

Epe

140

227

-21

Table 2: Lagos state HW requirements, available, shortfall, and available by LGAs and total number after pairing of LGAs. 

     

G

iostyles

   

Cold Boxes (RCWs)

   

Ice-Packs

   

LGA

No of Teams

No Of Wards

Required

Giostyle (2/

Team)

Available Giostyle

Giostyle Shortfall

Rush Available

RCW

Required 2/

Ward

RCW

Available

Gap

Required

(0.3/0.4 Icepack/Giostyle) 4

Rrequired

(0.6 Ice-Pack/

RCW 24

Total

Required

Total Available

Ice-Pack Shortfall

Agege

174

13

348

250

-98

 

26

30

4

2784

624

3408

869

-2539

Ajeromi/Ifelodun

326

16

652

323

-329

 

32

16

-16

5216

768

5984

2633

-3351

Alimosho

518

36

1036

448

-588

98

72

40

-32

8288

1728

10016

9977

-39

Amuwo Odofin

132

14

264

100

-164

 

28

20

-8

2112

672

2784

1300

-1484

Apapa

80

12

160

105

-55

 

24

21

-3

1280

576

1856

1569

-287

Badagry

191

20

382

232

-150

195

40

40

0

3056

960

4016

3074

-942

Epe

104

19

208

116

-92

 

38

43

5

1664

912

2576

2362

-214

Eti Osa

102

20

204

132

-72

 

40

30

-10

1632

960

2592

1800

-792

Ibeju Lekki

103

12

206

92

-114

 

24

19

-5

1648

576

2224

1270

-954

Ifako/Ijaye

228

14

456

421

-35

 

28

30

2

3648

672

4320

4019

-301

Ikeja

158

18

316

411

95

 

36

22

-14

2528

864

3392

2556

-836

Ikorodu

358

30

716

421

-295

87

60

60

0

5728

1440

7168

1620

-5548

Kosofe

180

21

360

297

-63

 

42

42

0

2880

1008

3888

4310

422

Lagos Island

100

20

200

141

-59

 

40

32

-8

1600

960

2560

3844

1284

Lagos Mainland

148

18

296

158

-138

 

36

32

-4

2368

864

3232

2440

-792

Mushin

350

19

700

365

-335

 

38

25

-13

5600

912

6512

3128

-3384

Ojo

489

15

978

285

-693

265

30

24

-6

7824

720

8544

2844

-5700

Oshodi/Isolo

359

20

718

234

-484

 

40

35

-5

5744

960

6704

2160

-4544

Shomolu

182

16

364

155

-209

 

32

32

0

2912

768

3680

3168

-512

Surulere

243

23

486

299

-187

 

46

47

1

3888

1104

4992

2028

-2964

Total

4525

376

9050

4985

-4065

645

752

640

-112

72400

18048

90448

56971

-33477

Table 3: Lagos state 2017/18 MVC Cold-chain equipment requirements, available and shortfall.

In summary, as shown in table 3, there were shortfalls in all fast CCE equipment required for the campaign across the LGAs in the state. For giostyle, 19/20 (95%) of the LGAs had inadequate vaccine carriers while 12/20 (60%) of the LGAs had shortfall in cold boxes and 18/20 (90%) LGAs had inadequate ice packs.

The staggering of the campaign and pairing of the LGAs helped to reduce the shortfall in CCE as shown in table 4. After pairing the LGAs, 14/20 (70%) LGAs had adequate or excess giostyle, 19/20 (95%) LGAs had adequate or excess cold boxes and 12/20 (60%) LGAs had excess icepacks. For LGAs that still had shortfall of CCEs after the pairing, the state, based on earlier staggering communication to the LGAs, moved CCEs from LGAs with excess to those LGAs. For example, Alimosho despite the support gotten from Ikeja LGA still received giostyle from Agege (a close LGA) to bridge their gap in cold boxes and icepacks.

Recycling of icepacks was jettisoned during the SIAs. To mitigate this problem the state and LGAs ensured regular supply of power (≥ 12 hours) in the LGA cold stores by providing funds for fueling of generator in addition to the power from the national grid. This ensured that there was adequate power supply for baking of ice packs as soon as the vaccination teams closed for the days’ work. Table 4 shows the Cold-chain equipment requirements, availability, shortfall, and available CCEs after pairing of LGAs.

LGA

No of Teams

No Of Wards

No of HFs

Required

Giostyle

(2/Team)

Available

Giostyle after pairing

Giostyle Shortfall

Rush Available

RCW

Required 2/

Ward

RCW

Available after pairing

Gap

Required

(0.3/0.4

Ice-pack/

Giostyle) 4

Rrequired (0.6 IcePack/

RCW 24

Total

Required

Total Available

Ice-Pack Shortfall

           

PHASE 1 LGAs

             

Alimosho

518

36

5

1036

779

-257

147

72

62

-10

8288

3456

11744

11277

-467

Ojo

489

15

122

978

517

-461

 

30

64

34

7824

1440

9264

5918

-3346

Ikorodu

358

30

3

716

718

2

 

60

60

0

5728

2880

8608

5930

-2678

Mushin

350

19

13

700

664

-36

 

38

72

34

5600

1824

7424

5156

-2268

Ajeromi/ Ifelodun

326

16

86

652

428

-224

10

32

37

5

5216

1536

6752

4202

-2550

Agege

174

13

10

348

671

323

 

26

30

4

2784

1248

4032

4888

856

Lagos Mainland

148

18

49

296

313

17

 

36

64

28

2368

1728

4096

5608

1512

Amuwo

Odofin

132

14

74

264

334

70

15

28

55

27

2112

1344

3456

3460

4

Epe

104

19

18

208

208

0

6

38

43

5

1664

1824

3488

3632

144

Lagos

Island

100

20

41

200

273

73

 

40

62

22

1600

1920

3520

5644

2124

           

PHASE 2 LGAs

             

Oshodi/ Isolo

359

20

130

718

334

-384

 

40

55

15

5744

1920

7664

3460

-4204

Surulere

243

23

8

486

664

178

 

46

47

1

3888

2208

6096

5156

-940

Ifako/Ijaye

228

14

79

456

671

215

 

28

30

2

3648

1344

4992

4888

-104

Badagry

191

20

90

382

517

135

220

40

40

0

3056

1920

4976

5918

942

Shomolu

182

16

42

364

313

-51

 

32

32

0

2912

1536

4448

5608

1160

Kosofe

180

21

13

360

718

358

 

42

42

0

2880

2016

4896

5930

1034

Ikeja

158

18

80

316

411

95

 

36

62

26

2528

1728

4256

11277

7021

Ibeju Lekki

103

12

53

206

208

2

 

24

62

38

1648

1152

2800

3632

832

Eti Osa

102

20

76

204

273

69

156

40

62

22

1632

1920

3552

5644

2092

Apapa

80

12

615

160

428

268

64

24

37

13

1280

1152

2432

4202

1770

Table 4: Lagos state 2017/2018 MVC Cold chain equipment requirements, available and shortfall after pairing of LGAs.

Assessment of Human resources

The 2018 Lagos state measles vaccination campaign microplan estimated a total of 3,660,480 children aged 9 to 59 months to be reached during the campaign. A total of 4,474 vaccination teams over a 6-day period were needed to reach this population. This was arrived at using the work load expected per team per day taking into consideration the urban and rural wards in the state. A vaccination team is made up of 7 team members which include 2 health workers qualified to give injectables who serve as vaccinators. Other members of the vaccination team are; two recorders, one town announcer, one community leader that doubles as the crown controller and one house to house mobilizer.

We reviewed the human resource available in the state by identifying the number of health workers qualified to give injectables (doctors not included) in all Local Government Areas (LGAs) of the state. A total of 3,769 qualified health workers were identified across all 20 LGAs as available for the vaccination campaign. Lagos state unlike most of the states in Nigeria has the highest concentration of qualified health workers (nurses, midwives, community health officers and retired nurses/midwives). However, not all qualified health workers were deployed for the measles vaccination campaign as other services could not be shut down because of the campaign. For example, Mushin LGA that has the Lagos University Teaching Hospital (a tertiary health facility) has over a thousand nurses and midwives but only three hundred were available for the vaccination campaign. From the microplan data, a total of of five thousand, three hundred and ninety eight (5,398) qualified to give injectable health workers were identified across the 20 LGAs, but three thousand, seven hundred and sixtynine (3,769) were found to be available for the measles vaccination campaign. The state was expected to have 8,948 qualified health workers to reach its target population. This left the state with a gap of 5,179 health workers. Table 2 shows the required, available, shortfall and the total number of health workers available after pairing of LGAs in Lagos state. Ojo LGA despite the support from Badagry LGA still had the highest number of Human Resources for Health (HRH) gaps as well as Giostyle so did intra - LGA staggering, where all the available resources were deployed to finish the work in some wards before moving to the remaining wards during the phase one implementation.

The phase one LGAs with a target population of 2,298,667 required 5,174 health workers, 5,398 vaccine carriers, 400 cold boxes and 52,784 ice packs (0.3/0.4 and 0.6). The phase two LGAs had a target population of 1,361,813 required 3,774 health workers, 3652 vaccine carriers, 352 cold boxes and 37664 ice packs (0.3/0.4 and 0.6). The pairing of the LGAs ensured that there was adequate number of health workers to implement the campaign in each phase. However, despite the pairing of the LGAs, there was still a shortage of vaccine carriers.

In terms of the campaign outcome looking at the coverage, 19 of the 20 LGAs in Lagos state had an administrative coverage above 95%. One LGA (Apapa LGA) had 73%. The end process monitoring data however, revealed that all the 20 LGAs had coverages above the set target of 95%. These administrative and the end process monitoring coverage are illustrated in figure 6. The state also had a post-campaign coverage survey of 94%, which was the 9th best-performing state in the country.

Discussion

Nigeria has implemented several measles SIAs and one of the major challenges is the availability of qualified health personnel and CCEs to reach the huge target populations for these campaigns. In the 2017/2018 measles vaccination campaign, the National Primary Health Care Development Agency (NPHCDA) inaugurated the National Measles Technical Coordinating Committee (NMTCC) charged with the responsibility of coordinating and providing technical guidance to the states for a quality campaign. Having identified the gaps in HRH, CCEs, supervisors, and monitors, the campaign was changed from the normal two phases of National campaigns as done in the past into three phases (Figure 1). NMTCC is made up of government and Partner Agencies supporting immunization in the country. As the country got closer to the implementation dates, the resources gaps became more glaring based on the verification of the micro plans, and the country implemented the campaign in four streams (Figure 2) across geopolitical zones, against the initially planned three phases.

 

Figure 1: Proposed phasing of the 2017/2018 measles vaccination campaign in Nigeria.