PAS coalition at the national level continued to participate and support the National Emergency Routine Immunization Coordination Centre (NERICC) meetings for improved coordination of immunization programs in Nigeria. The Expanded NERICC meetings include State Emergency National Routine Immunization Coordination Centre (SERICC), State Immunization Officers (SIOs), State Emergency Maternal and Child Intervention Centre (SEMCHIC), Reproductive Maternal Newborn & Child Adolescent Health +Nutrition (RMNCH+N), and National Primary Health Care Development Agency (NPHCDA) State Coordinators. SERICC meetings are aimed at improving immunization coverage at the State level.

During the 3^rd quarter of 2020, PAS-CSOs at the National and State levels played significant roles across the RI platforms; held government accountable at local, state and federal levels, and provided technical inputs. The key issues discussed and contributions of the PAS sub-grantees were disaggregated by national and states below.

PAS-CSO; Medical Women Association of Nigeria (MWAN-PAS) participated and contributed actively in 10 National Emergency Routine Immunization Coordination Centre (NERICC) meetings held in August 2020. No NERICC meeting was held on 17th and 18th of August due to some tight schedule by the director. The key issues discussed and contributions of the PAS sub-grantee at NERICC meetings are below.

Update on Inactivated Polio Virus Vaccine 2 Introduction

NG-TAG, recognizing that good policy recommendations need to be evidence-based, feasible and dynamic, and considering the polio risk, global supply situation and pipeline, and affordability, recommended:

1. The use of fractional inactivated polio vaccine in routine immunization and SIAs program in Nigeria;

2. Fractional inactivated polio vaccine (fIPV) should be used to conduct catch-up campaign (intensified RI) in all the high transmission communities as stand-alone;

3. To ensure programmatic readiness, it should be introduced for the Routine immunization and SIAs in 2019; and

4. Based on its potent immunogenicity and compatibility with the current National RI schedule it should be introduced in Routine immunization schedule at 6 weeks and 14 weeks.

The Review of fIPV and full-dose IPV for second dose introduction in Nigeria was conducted based on WHO guidelines on IPV2 introduction. With regards to Seroconversion Rate, Full IPV has 95%, 91%, and 97% against polio virus types 1, 2, and 3 respectively. While Fractional IPV (fIPV) has 88%, 81%, and 89% for polio virus type 1 and 96%, 87%, and 97% for polio virus type 2. Vaccine Availability in 2021 showed that Full IPV is enough, but may have temporary global shortage, if all eligible countries planned to introduce it in 2021. While fIPV is same as for full IPV, though vaccine needs will be less and risk of supply shortages lower. The Cost of Vaccines for Full IPV is currently fully funded by GAVI, and timelines for transition of funding to government have not been confirmed. While fIPV will be fully funded by GAVI, will be cheaper for the country when GAVI stops full financing of IPV. With respect to Storage Requirement, Full IPV will require double the storage capacity of current IPV1 at 0.5ml per dose while fIPV will require less storage capacity at 0.1ml. Full IPV is administered by intramuscular (IM) on the thigh while fIPV is given intradermal (ID) on the upper arm. A review of the Health Worker Knowledge showed that no significant training is required for health worker on Full IPV, while fIPV will require extensive re-orientation of health worker on IPV administration. Countries should carefully consider any switch from fractional to full dose, or vice-versa, taking into account cost-effectiveness, logistics and programmatic considerations.

Priority Activities to be Implemented to Improve RI in Nigeria

Priority activities include;

1. New vaccine introduction including development of HPV proposal and development of training material for HPV;

2. Program management and coordination – supporting state to modify work plan and prioritize key activities in line with COVID context;

3. New vaccine introduction including development of Rota training materials;

4. Program management and coordination – conduct virtual meetings of NERICC. Key activities include; Routine immunization teams will review RI performances as well as chart ways forward fortnightly in the first quarter and then on a monthly basis /on need, Conduct a financial mapping of existing resources within each state (SOML, State and partners funds) to identify potential funding sources and develop evidence- based advocacy kits to assist in domestic resource mobilization for RI and PHC, and Provision of Zoom licenses to SERICC/RIWG/SLWG/ SEMCHIC to attend virtual meetings.;

5. Data Management activities which entails providing technical support towards the conduct of data review meetings across all states;

6. New Vaccine Introduction including development of IPV2 proposal;

7. Advocacy, Communication and Social Mobilization – Using SMS platform to send targeted messages to HCWs;

8. Program Management and Coordination activities include identifying poor performing LGAs and conducting review meetings with poor performing LGAs on strategies to improve RI;

9. Service Delivery Activities include supporting States to develop and implement the RISS plan, Review of indicators for RISS, Creation of dashboards, Review of RISS database, Plan RI intensification for the next 3 months in the identified poor performing LGAs, and Provision of adequate PPE for HCWs to provide quality services.

Impact of Covid-19

The Covid-19 pandemic has stretched the primary health care system with health workers saddled with more responsibilities. Implementation of fixed and outreach sessions are limited by several challenges including difficulty in accessing health facilities by health workers and caregivers due to transportation challenges and initial suspension of outreaches due to community transmission. There has been disruption in vaccine deliveries and shipments with delays lasting up to two months and decline in consumption of available vaccines observed with the onset of the pandemic. Demand creation activities have also been stalled with fears and rumours imposing additional access barriers due to Covid-19.

Review of RI and other PHC services utilization data from national DHS2 data and visit to Lagos State by the PTF team confirm a decline in the PHC services utilization. Health care seeking behaviour of the citizenry has also been adversely affected by negative perceptions of Covid-19. Primary health care activities (RMNCH+N & R) have been disrupted due to Covid-19 pandemic. Health workers are saddled with Covid-19 response while patients are weary of visiting PHC due to fear of the risk of infection. With increasing number of cases, there is an increasing need to optimize primary health care service provision. The Agency has developed innovative strategies to address the decline in service utilization and ensure continuance and optimization of services utilization at the PHCs. The Covid-19 has further worsened the already poor maternal and child health indices in the country. There is decline in ANC1 and ANC 4+ visits with the onset of Covid-19. There is a decline in facility-based deliveries with the highest margin of difference in May 2020. The uptake of immunization and RMNCH + N services has been affected with the onset of Covid-19 outbreak. Comparisons of Penta 3 between 2019a and 2020 showed decrease in performance in the months affected by Covid-19 outbreak.

Planning Meeting for the Conduct of MICS/NICS 2020

Donor meeting was held on the 4th August 2020. Key points discussed are:

• Country’s performance during the MICS/NICS 2016/17 at 33% which was very poor.

• With the support from all the partners, leadership of NPHCDA and Minister, progress was observed when the NDHS 2018 performance improved to 57% as well as SMART 2019.

• Government and partners agreed with one voice to conduct the survey in fourth quarter of 2020. Covid-19 would not be a hindrance. Although Covid-19 has come to stay for some time. It is better to move on with the process.

• 487 enumerators will be trained physically at 18 per state and will not be delayed. Given that 200,000 Health Workers were trained in peak of Covid-19 by Government, Services have resumed, Health Facilities are open, and outreaches are being conducted, so there is need to move on.

• Manual on the protocol on how the Health Workers can stay offering their services could be shared with the NBS team and be used in the training of the enumerators.

• UNICEF is ready and assurance of all other partners.

Regular MICS/NICS meeting was held on the 5th August 2020. Highlights from the donor meeting and agreement on the budget presentation will be shared later, for presentation at the CORE GROUP meeting to ascertain the gaps for further commitment from partners. Efforts will be made to ensure that results are released in a timely manner and understood by everyone. The MICS Global team said there is need to compress the questionnaire and have control over the quality of data to be generated since MICS has a large questionnaire, to be able to drop some modules/indicators from the survey. On the sampling frame, survey would be conducted in 36 states and FCT in 50 EAs per state, supplemental EAs in 16 States in 20HH per EA, a total of 2190 EAs and 43,800 HHS to be canvassed.

Challenges and Recommendations

1. Stock out vaccines during the conduct of sessions in some HFs in Kaduna, Niger, and Sokoto States. Recommendations were State desk officers to follow-up with the states and provide feedbacks to NERICC. And the timeline for this was 27th August and is ongoing.

2. Sub-optimal conduct of supportive supervision during fixed and outreach sessions in most states. Recommendations were State Desk officers to follow up with the states and provide feedback to NERICC.

Understanding the Key Drivers of Poor Data Quality and Use for Improved Management of PHC and Immunization Programs in Nigeria

Data-driven planning and use for action in PHC context is important in improving health outcomes and enhancing programs efficiency. Despite ongoing data quality improvement initiatives, issues still persist. Insight from behavioural science perspective will help to determine key drivers of data quality, usability, and use at the LGA and HFs level as well as inform intervention design.

CHAI and AFENET, in collaboration with the NPHCDA, FMOH, SPHCB, and SMOH in 8 States will conduct this study to understand the key drivers of poor data quality, usability and use across different levels in Nigeria. Findings will be shared with the government and relevant stakeholders to inform the design of context specific interventions to improve PHC data quality in Nigeria. The Study Objectives include; identify the key drivers of poor PHC data quality, usability and use for action at the LGA and HF levels; identify non-financial incentives that reinforce positive HCW practices, accurate data entry and use of data for action; and to document perception and attitude of stakeholders on PHC data quality.

The timeline for the project implementation spans over a period of ten weeks. Pre-Assessment Phase activities include obtain ethical approval, field test tool. (June – October 2020). Assessment Phase include; Train research assistants and collect data in Niger (24/08 – 4/9/2020), and Train research assistance and collect data simultaneously in other states. (31/8 – 9/9/2020). Data Analysis and reporting phase are Transcribe interviews and clean data for Niger. (31/8-6/9/2020), Transcribe interviews and clean data for other states (10/9-16/9/2020), Code and analysis data for Niger (7/9/20-20/9/2020), Code and analyse data for other states (17/9- 4/10/2020), and Write and submit report (5/10-23/10/2020).

FMoH Update on Health Facility Updating

Health facility update has been carried out in 33 States, and it is expected that the remaining 3 States including FCT will be completed by August ending. they will complete. The process of this health facility updating is very confusing to some state officers because they feel it is not beneficial to them as a lot of facilities have not yet been captured.