Introduction
Primary health care (PHC) is considered the pillar of health care systems because it aims to reduce health-related inequities and enhance access to health care. It is regarded as essential, universally accessible and affordable health care founded on interventions that have been scientifically proven (UNICEF 2008). PHC is comprised of the following elements: “health education, adequate nutrition, maternal and child health care, basic sanitation and safe water, control of major infectious diseases through immunization, prevention and control of locally endemic diseases, treatment of common diseases and injuries, and the provision of essential drugs” (UNICEF 2008).
However, decades after the 1978 Alma Ata Convention which established PHC, issues regarding access and equity still abound in many countries including Nigeria. Despite being a cost-effective strategy to prevent disease, for instance, universal immunisation coverage remains an elusive goal in this country. Rates of uptake are among the lowest globally and translate to poorer health outcomes such as increased incidences of under-five mortality and morbidity with easily preventable diseases. Clearly, changes need to be made to improve the situation. To better comprehend why this phenomenon persists and what health workers can do, the PHC system, extent of immunisation uptake, the barriers to uptake and strategies to overcome these barriers need to be ascertained. Focus will be given to childhood immunisation with BCG in the context of Okrika, Nigeria.
The Primary Health Care System in Nigeria
Nigeria has a three-tiered political system composed of the federal government, the state and the local governments (Antai 2012). According to Chukwuani et al. (2006), the provision of PHC services has been devolved to the level of the local government council (LGC) of a local government area (LGA). Within this structure, villages have health posts while clusters of villages beneath the district level have health clinics. A primary health care centre serves every health district while LGAs are serviced by general hospitals or comprehensive health centres. The organization of primary health care facilities also represent the referral system where outposts refer patients to health clinics which then refer patients to the PHC centres which then refer patients to the general hospitals or comprehensive health centres.
The PHC system in Nigeria aims to provide the following services consistent with the elements of PHC: sufficient nutrition through support to agriculture, health education, sanitation and safe water supply, under-five immunization, child and maternal health coupled with family planning, basic drugs, treatment for uncomplicated or minor conditions, control over endemic and non-communicable disease, oral health and mental health services (Chukwuani et al. 2006). Based on national policy, these services are supposed to be made available in all levels of the PHC system to facilitate access by the population.
The State of Immunisation Services Delivery
An approach called “Reaching Every Ward” (REW) was developed in Nigeria in 2004 with the aim of increasing and sustaining rates of routine immunisation. It was the application of the WHO’s Reaching Every District (RED) strategy to the context of Nigeria’s wards which represent the basic level of political administration. REW was defined as “a strategy aimed at the provision of regular, effective, quality and sustainable routine immunization activities in every ward, so as to improve immunization coverage” (USAID 2009, p.1). The REW was implemented nationwide in 2006. However, an assessment conducted a year after showed that among the target facilities and areas, less than 50% actually practiced the strategy.
A baseline assessment done by the USAID in the states of Sokoto and Bauchi following the REW implementation revealed an inadequate number of health professionals who compose just 40% and 44% of PHC facility staff respectively (Hasselblad et al. 2007). Immunisation services were also generally insufficient and provided irregularly as evidenced by only 28% of facilities in Bauchi and 48% in Sokoto providing them for a four-month period or more (Hasselblad et al. 2007). While outreach visits were done to deliver immunisation services, these were also done sporadically with poor documentation of uptake. LGA documents confirm that vaccine and supplies distribution were not regularly scheduled, plans were not transparent, data monitoring and record-keeping was not done systematically, future needs were not projected, and there was minimal supervision of health care workers which were inconsistent with the features of the REW (Hasselblad et al. 2007). Since then, reforms have been underway to improve implementation.
Immunisation Coverage in Nigeria
Among the ten PHC services, immunisations are the most utilised. Through the National Programme on Immunisation (NPI) administered by the Federal Ministry of Health, polio, combined diphtheria-pertussis-tetanus, measles, BCG, yellow fever and hepatitis B vaccines are made available to children below the age of five years old providing them protection against seven diseases (Abdulraheem et al. 2011). The costs of vaccines and its delivery are shouldered by the three levels of government (Ngowu, Larson & Kim 2008). However, though 90% of children have been targeted, only 13% on the average have achieved full immunisation with some of the northern states having coverage rates of less than 1% (Udonwa et al. 2010). Trends show a steady decline in vaccine coverage since the 1980s and are not surprising given the current state of the service delivery system.
In the prevention of tuberculosis, Bacille Calmette-Guerin (BCG) is the only effective vaccine and has been in use since 1921 (WHO 2012). Although the WHO recommends that the vaccine be given as soon as possible after birth, many children in Nigeria actually receive it at varying ages (Wammanda, Gambo & Abdulkadir 2004). This finding may be the result of limited access and awareness as being born in a general hospital compared to the home is associated with a higher likelihood of early BCG vaccination. Further, data show that coverage with BCG vaccine has reached only as high as 53.1% in the southern region and as low as 20.5% in the Northwest (National Immunization Coverage Survey 2007). In my personal experience as a volunteer in Okrika, a southern city, utilization of the vaccine in a primary health care facility was just roughly 50%. The negative impact of these low coverage rates can be fully appreciated in light of the fact that 95-percent coverage is necessary if outbreaks are to be prevented in the population (Abdulraheem et al. 2011). Resurgence in tuberculosis has been noted in Nigeria recently and among children, the disease remains a chief cause of childhood mortality and can only be attributed to low BCG uptake (Jiya, Bolajoko & Airede 2008).
Barriers to Immunisation Uptake
Antai (2011) notes that immunisation services are governed by supply and demand where supply represents the health care delivery system and demand represents the attributes of the children and their caregivers. Supply has been noted to be higher in urban areas compared to rural areas while demand is influenced by mothers’ attitudes and their knowledge or awareness regarding immunisation. In studies, the three most cited reasons for failure to utilise vaccination services are inadequate or no supply of vaccines, sites located far from home and insufficient awareness (Udonwa et al. 2010; FBA HSA 2005). The first two reasons reflect problems with supply which is the major determinant of coverage and the third factor relates to demand which is a secondary determinant (Antai 2011).
In a survey conducted in Awe, a rural LGA, regarding why children miss their vaccinations or never complete them, mothers validated the three reasons mentioned above when they cited the need to walk long distances to reach vaccination sites and then finding out that there were no vaccines available on the scheduled day (Abdulraheem et al. 2011). Knowledge and attitudes also deterred vaccination uptake when participants stated that their negative perceptions on the safety of immunisations especially with their children’s prior experience immunisation-related complications kept them from returning for subsequent doses (Abdulraheem et al. 2011; FBA HSA 2005). Further, of the respondents representing 85 villages, only 12.8% were aware that the BCG dose should be given the soonest possible after birth, and only 14.1% were aware that complete vaccination should be achieved by the time the infant is nine months old (Abdulraheem et al. 2011). Long waiting times, child or mother’s illness on the day of vaccination, being unaware of immunisation schedules or forgetting them, and the indirect costs involved when family finances are scarce have also been identified as barriers.
Community Participation in Primary Health Care
Community participation is one of the fundamental principles of PHC conceptualised by the WHO. It is defined as " an educational and empowering process in which the people, in partnership with those who are able to assist them, identify the problems and the needs and increasingly assume responsibilities themselves to plan, manage, control and assess the collective actions that are proved necessary" (Roy & Sharma 1986, p.166). One strategy to gain community participation is through the target-oriented approach characterised by professionals being in control over program objectives after which community participation through acceptance of the program is sought (Rifkin 1996). The initiative is regarded as an intervention and is evaluated in terms of quantitative outcomes such as by how much health status has improved. Participative approaches have been used in various areas of primary health care in Nigeria such as in designing and delivering services related to maternal health (Doctor et al. 2012) and in the delivery of treatments for TB (Kironde & Kahirimbanyi 2002).
Community Participation in Immunisation Services Delivery
Community participation using the target-oriented approach has proved indispensable in the successful planning, implementation and sustainability of childhood immunisation initiatives based on a project introduced in two Nigerian states. With the less than expected success of the REW as mentioned above, the USAID assisted the Nigerian government in planning and implementing a participative approach called IMMUNIZATIONbasics which began in 2006 and piloted in the states of Bauchi and Sokoto (USAID 2009). Since baseline assessment showed weaknesses in the capacity of the current delivery system, the project’s first priority was to strengthen infrastructure and resources including health worker skills. Health facilities were made fully functional and client friendly and staff were adequately trained. Once these were achieved, the next priority was to facilitate the greater involvement of the community in order to increase access to and use of enhanced immunisation services.
Community participation was obtained whenever the opportunity arose. Traditional leaders were involved in crucial meetings advocating routine immunization as they were the key to buy-in of the project by the community (USAID 2009). Community meetings became possible and were venues for participation in planning and in activities like the mapping of catchment areas. Community awareness about the different aspects of immunisation was also developed during these meetings as were linkage and interaction between health workers and community members as community issues regarding PHC were addressed.
Other opportunities for community involvement were birth registry updating which were accomplished during traditional ceremonies when newborns are named. It was deemed important to maintain accurate birth registries so that immunisation coverage rates could be monitored and drop-outs could be followed up (USAID 2009). Following up children and their caregivers is another venue for community participation and ensures that all children are able to obtain full immunization within their first year of life. Community members can also be involved in immunisation outreach planning, helping transport staff and supplies to the outreach sites, disseminating information in the village about the scheduled immunisation and the arrival of the staff, and identifying and building sites for the safe disposal of injection waste materials (USAID 2009).
Improving BCG Uptake in the Context of Okrika, Nigeria
In planning an immunisation initiative for implementation in Okrika, I will apply the findings generated in literature. Taking into account that Okrika is an urban area, the supply of BCG vaccines and materials needed for administration is unlikely to be the more significant problem as compared to rural areas. At the same time, effecting changes in the health care service delivery system necessitates reforming the present political structure which is a long term and collective goal. As a health worker returning to my home in Okrika, a shorter term goal and my main concern would be regarding the demand side. Using a target-oriented approach, the aim of an immunisation initiative which I can propose would be to increase BCG utilisation to at least 95% in order to ensure that childhood morbidity and mortality related to tuberculosis will be significantly reduced and outbreaks will be prevented. The optimum age of receiving the vaccine, which is at birth, will also be advocated.
Based on studies regarding barriers to immunisation services uptake, demand is largely determined by mothers’ knowledge and attitudes. Using a participative approach, awareness building through education will be planned and implemented consistent with the community’s right to information. The objectives would be to dispel negative perceptions about vaccination, provide adequate information about adverse events, discuss the health benefits of immunisation, outline the optimum dose, schedule and types of vaccines recommended for children and the rationale behind them, and encourage and respond to concerns or issues regarding childhood vaccination. The initiative must be conducted prior to scheduled childhood immunisations in order to optimise higher rates of uptake that can be generated by increased knowledge and more positive attitudes.
The participation of traditional leaders who have authority over cultural beliefs and customs must be enlisted as they can help shape education programs which are acceptable. As they are influential in the community, members will tend to participate if they see that their leaders support the initiative. Community meetings are the most ideal venues to build awareness through education activities as these can be scheduled when target participants are most likely to be available and in locations that are accessible to them. The possible roles of the community are to shape the content of education activities so that these address their learning needs and at the same time generating key messages which will be consistently used as themes. Other roles would be to determine the schedule and venue of community meetings, to secure the equipment needed, mobilise others to attend possibly through mass media or home visits, and monitoring attendance to quantify those reached by the program.
Conclusion
Rates of BCG coverage among Nigerian children remain low at present. Although a primary health care system is in place in the country, factors related to the health care delivery system and the client constrain utilisation of vaccination services. Mothers’ knowledge about immunisation and their attitudes are major influences to service utilisation. In designing programs to improve awareness and knowledge and thereby increase coverage rates, community participation must be enlisted for implementation to be successful. In the context of Okrika, Nigeria, a participative public education program for the said purpose is feasible and is one way in which health workers can modify the trends of declining immunisation uptake and improve the health and wellbeing of children.
Bibliography
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Appendix 1
The Search Strategy
The issues discussed in this essay were derived from a review of literature on the subject of immunisation uptake in Nigeria. In order to retrieve this literature, the following search was performed. The databases African Journals Online (http://www.ajol.info/), PubMed (http://www.ncbi.nlm.nih.gov/pubmed), ScienceDirect () and Academic Journals () were accessed along with the WHO (), UNICEF (http://www.unicef.org/) and USAID (http://www.usaid.gov/) websites.
The following keywords were entered: childhood immunisation and Nigeria, childhood vaccination and Nigeria, immunisation services and Nigeria, vaccination services and Nigeria, BCG and Nigeria, childhood tuberculosis and Nigeria, prevention of childhood tuberculosis and Nigeria, barriers to immunisation and Nigeria, barriers to vaccination and Nigeria, primary health care and Nigeria, community participation and primary health care and Nigeria, community participation and immunisation and Nigeria.
Inclusion criteria specified were:
Studies done in the Nigerian setting
Studies on childhood immunisation or immunisation in children below 5 years old
Studies on community participation in primary health care
Studies on community participation in immunisation services delivery
Studies on prevention of childhood tuberculosis
Studies on barriers to immunisation uptake
Studies describing the primary health care system and immunisation services delivery
The above strategy resulted in 17 articles being retrieved. These articles have formed the basis of the issues discussed in this essay.
