1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
2School of Public Health, University of the Western Cape, Cape Town, South Africa
3i+Consortium, Abuja, Nigeria
4International Vaccine Access Center, Johns Hopkins School of Public Health, Baltimore, MD, USA
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.
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.
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.
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.
Berlan D, Shiffman J. Holding health providers in developing countries accountable to consumers: a synthesis of relevant scholarship. Health Policy Plan. 2012;27(4):271-280. doi:10.1093/heapol/czr036
Molyneux S, Atela M, Angwenyi V, Goodman C. Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework. Health Policy Plan. 2012;27(7):541-554. doi:10.1093/heapol/czr083
Cleary SM, Molyneux S, Gilson L. Resources, attitudes and culture: an understanding of the factors that influence the functioning of accountability mechanisms in primary health care settings. BMC Health Serv Res. 2013;13:320. doi:10.1186/1472-6963-13-320
Brinkerhoff DW, Bossert TJ. Health governance: principal-agent linkages and health system strengthening. Health Policy Plan. 2014;29(6):685-693. doi:10.1093/heapol/czs132
Freedman LP, Schaaf M. Act global, but think local: accountability at the frontlines. Reprod Health Matters. 2013;21(42):103-112.
United Nations Secretary General. Global Strategy for Women's and Children's Health. New York: Partnership for Maternal, Newborn and Child Health; 2010.
Every Woman Every Child. Global Strategy for Women's, Children's, and Adolescents' Health (2016-2030). New York, NY; 2015.
Murthy RK, Klugman B. Service accountability and community participation in the context of health sector reforms in Asia: implications for sexual and reproductive health services. Health Policy Plan. 2004;19 Suppl 1:i78-i86. doi:10.1093/heapol/czh048
Garba AM, Bandali S. The Nigeria Independent Accountability Mechanism for maternal, newborn, and child health. Int J Gynaecol Obstet. 2014;127(1):113-116. doi:10.1016/j.ijgo.2014.07.004
George A. 'By papers and pens, you can only do so much': views about accountability and human resource management from Indian government health administrators and workers. Int J Health Plann Manage. 2009;24(3):205-224. doi:10.1002/hpm.986
Dixon A, Storey J, Rosete AA. Accountability of foundation trusts in the English NHS: views of directors and governors. J Health Serv Res Policy. 2010;15(2):82-89. doi:10.1258/jhsrp.2009.009078
Federal Ministry of Health Nigeria, World Health Organization. Report of the National Workshop on Strengthening Results and Accountability for Women's and Children's Helath and the Entire Health Sector. Abuja: World Health Organization; 2013.
National Population Commission (NPC) [Nigeria] and ICF International. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA; 2013.
Institut National de la Statistique (INS) et ICF International. Enquête Démographique et de Santé et à Indicateurs Multiples du Cameroun 2011. Calverton, Maryland, USA; 2012.
Ghana Statistical Service (GSS) GHSG, and ICF International. Ghana Demographic and Health Survey 2014. Rockville, Maryland, USA; 2014.
Stokes-Prindle C, Wonodi C, Aina M, et al. Landscape Analysis of Routine Immunization in Nigeria: Identifying Barriers and Prioritizing Interventions. Baltimore, Maryland, United States: International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health; 2012.
Onwujekwe O, Hanson K, Uzochukwu B. Are the poor differentially benefiting from provision of priority public health services? A benefit incidence analysis in Nigeria. Intl J Equity Health. 2012;11:70. doi:10.1186/1475-9276-11-70
Pierre L. Routine Immunization Programme of Nigeria Vaccine Audit Report. Findings and Recommendations. Abuja, Nigeria: National Primary Health Care Development Agency, Federal Ministry of Health and World Health Organization; 2012.
National Primary Health Care Development Agency WHO. Data Quality Self-Assessment (DQS) Report. In: National Primary Health Care Development Agency FMoH, ed. Abuja, Nigeria; 2013.
Federal Ministry of Health Nigeria. National Strategic Health Development Plan (NSHDP) 2010-2015. Published 2010.
National Primary Health Care Development Agency. Integrating Primary Health Care Governance in Nigeria: PHC Under One Roof. Published 2013.
National Primary Health Care Development Agency. Guideline for Establishment of State Primary Health Care (PHC) Board in Nigeria. Abuja, Nigeria; 2012.
National Primary Health Care Development Agency. Primary Health Care Under One Roof Implementation Scorecard III Report. Published 2015.
Schedler A, Diamond L, Plattner MF. The Self-restraining State: Power and Accountability in New Democracies. Boulder, Colorado, United States: Lynee Riener Publishers; 1999.
Joshi A. Service Delivery: Review of impact and effectiveness of transparency and accountability initiatives. Brighton, Sussex: Institute of Development Studies, University of Sussex; 2010.
National Population Commission (NPC). 2006 Population and Housing Census: National and State Population and Housing Tables. Priortity Tables (Vol 1). Published 2006.
National Primary Health Care Development Agency. National Routine Immunization Strategic Plan 2013-2015. In: National Primary Health Care Development Agency FMoH, ed. Abuja, Nigeria; 2013.
George AS, Erchick DJ, Zubairu MM, Barau IY, Wonodi C. Sparking, supporting and steering change: grounding an accountability framework with viewpoints from Nigerian routine immunization and primary health care government officials. Health Policy Plann. 2016;31(9):1326-1332. doi:10.1093/heapol/czw057
Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. Piscataway, NJ: Aldine Transaction; 1967.
Corbin J, Strauss A. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Thousand Oaks, CA: Sage; 1990.
Garuba H, Kohler J, Huisman A. Transparency in Nigeria's public pharmaceutical sector: perceptions from policy makers. Global Health. 2009;5:14. doi:10.1186/1744-8603-5-14
McCoy DC, Hall JA, Ridge M. A systematic review of the literature for evidence on health facility committees in low- and middle-income countries. Health Policy Plan. 2012;27(6):449-466. doi:10.1093/heapol/czr077
Cleary SM, Gilson L. Accountability mechanisms in primary health care: What is the evidence for functioning? Published 2012.
International Vaccine Access Center. Conference report. Paper presented at: Niger State Accountability Framework Workshop; July 22-23, 2014.
National Primary Health Care Development Agency, United Nations Children's Fund, World Health Organization, US Centers for Disease Control. Nigeria Vaccine Wastage Assessment. Published 2011.
O’Connell M, Wonodi C. Routine immunization consultant program in Nigeria: a qualitative review of a country-driven management approach for health systems strengthening. Global Health: Science and Practice. 2016;4(1):29-42. doi:10.9745/ghsp-d-15-00209
Abimbola S, Olanipekun T, Igbokwe U, et al. How decentralisation influences the retention of primary health care workers in rural Nigeria. Glob Health Action. 2015;8:26616. doi:10.3402/gha.v8.26616
Eme OI, Izueke E, Ewuim N. Local government and fiscal autonomy for local government In Nigeria. Rev Public Adm Manag. 2013;7:112-120.
Meghani A, Abdulwahab A, Privor-Dumm L, Wonodi C. Basket Funds: A pooled arrangement to finance primary health care delivery and address the funding flow in Nigeria: International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health; 2015.
Bosch-Capblanch X, Garner P. Primary health care supervision in developing countries. Trop Med Int Health. 2008;13(3):369-383. doi:10.1111/j.1365-3156.2008.02012.x
Bosch-Capblanch X, Liaqat S, Garner P. Managerial supervision to improve primary health care in low- and middle-income countries. Cochrane Database Syst Rev. 2011(9):Cd006413. doi:10.1002/14651858.CD006413.pub2
Björkman M, Svensson J. Power to the people: evidence from a randomized field experiment on community-based monitoring in Uganda. Q J Econ. 2009;124(2):735-769. doi:10.1162/qjec.2009.124.2.735