By Charles Orjiakor (1), Prince Agwu (2), Aloysius Odii (3), Pamela Ogbozor (4), Obinna Onwujekwe (5) – Health Policy Research Group, College of Medicine, University of Nigeria, and Eleanor Hutchinson (6), Martin McKee (7), Dina Balabanova (8) – London School of Hygiene and Tropical Medicine
All authors are co-founding members of HSG’s new TWG Action on Accountability and Anti-corruption for the SDGs (TWG AAA-SDG).
On March 2, 2021, Nigeria received 3.94 million units of COVID-19 vaccine through the COVAX scheme and distribution is now underway. The National Primary Healthcare Development Agency (NPHCDA), operating under the Federal Ministry of Health, is at the forefront of the plan, taking proactive steps to disseminate information about the vaccines and setting up an online registration platform to facilitate registration and distribution.
This achievement in fighting the impact of COVID-19 means that Nigeria has become a leader in sub-Saharan Africa, but our experiences as researchers working among frontline health workers in primary care lead us to question whether vaccines will be distributed successfully and equitably. We are worried that, with time, ‘sharp practices’ (which are corrupt, exploitative, or unapproved practices), that we have seen undertaken by health workers in other routine (non-COVID) vaccination programs could be transferred to the COVID-19 vaccination program, so that vaccines may not reach the poor and vulnerable.
Studying primary health care vaccination practices
Ethnographic methods were applied to study primary health centres (PHC) in a state in Southeast Nigeria. Four researchers worked in 6 PHCs for an 8-week period, observing informal practices and talking to patients, community members, health workers, and other staff working in management/administrative roles about the rules that underpin their practices.
What was discovered?
We found three types of potential corruption in the PHC facilities:
1. Informal payments for childhood vaccines and associated commodities
2. Ineffective record-keeping of vaccine stocks
3. Diversion and sale of vaccines to the private sector
We saw informal payments in the administration of vaccines at all 6 PHCs, leading us to wonder how widespread this is in the country. One commonly observed type of informal payment in these facilities was where health workers solicit payments when they deliver vaccines to service users, including routine vaccines for children. When a recent outbreak of yellow fever occurred, the increased demand for vaccines was accompanied by greater informal payments. There is no fixed immunization price, and the process of setting fees involves considerable discretion based on personal relationships and the location of facilities. We witnessed payments ranging from 50 Naira to 200 Naira (USD$0.2 to $0.5) per immunization, and they seemed to be more frequent in health facilities based in urban settlements. The lower charges in rural facilities may reflect the lack of resources of those attending these facilities.
Health workers sought to justify vaccine-related informal payments, who explained that the fees covered the cost of consumables such as cotton wools, syringes, latex hand gloves, which were not supplied alongside the vaccine. But the payments made by service users are disproportionately high and cannot be justified by claims that they are for consumables. Officers-in-charge of health facilities also justify these payments as a source of critically needed revenue to run the underfunded health facilities and pay the volunteers they recruit to support the operation of facilities experiencing staff shortages. We also found evidence that vaccines were obtained and delivered by unqualified persons, in areas not appropriate for the purpose, without appropriate documentation, and without obtaining consent from parents whose children were vaccinated.
Our interviews confirmed that senior health managers at the local government (district) level were aware of the problem in at least two of the districts where the study was carried out but choose to ignore them. Some officials were reported to demand cuts from the proceeds of vaccination payments. Other officials only acted when the cases were brought to their desks. Although we were told by the local health authorities that officials in charge of PHCs have been instructed not to charge fees for vaccines, there was no significant pressure to clamp down on their demands for payment.
Additionally, accountability for storekeeping and the use of vaccines by health workers was opaque. There was substantial pressure to reconcile supplies of vaccine and use before the data are presented to donor agencies. We heard a health manager advising a facility manager to ensure that her immunization records tallied with what she sent to the district office because the donor agency was going to visit that facility to undertake an audit. This provided evidence of how data on vaccination can be altered at the facility level, something that remains easy as the process is yet to be digitalized.
Diversion of vaccines was experienced in one local government authority, with yellow fever vaccines being sold to the private sector for a fee. They also sold routine vaccines for newborn babies, inflating requests for vaccines by adding fictitious names to their records. The surplus vaccines were then sold to private facilities that depend on them for vaccine supplies. Private sector players then prescribe the vaccine for patients seeking treatment for exorbitant fees.
Recommendations for improved response
Early findings raise some important questions about how Nigeria can respond to the COVID-19 pandemic. We can make four recommendations.
1. Vaccines must be made available free of charge if we are to maximise uptake, especially among the poor.
2. A vial with a vaccine is of no use if there are no syringes, needles, cotton wool, and basic personal protective equipment for staff, so a vaccine program must supply all of these things together.
3. Strengthen supervision at facilities to curtail the sale of vaccines.
4. Speed up the pace of the ongoing program to digitalize management of supplies, necessary to track resources and support monitoring.
Research funded by the HSRI scheme with funding from the UK DFID, UK MRC, and Wellcome, with support from the UK ESRC, (grant no. MR/T023589/1).