From Sanusi Muhammad, Gusau
Introduction of Basket Funds Scheme for Immunization Financing in Nigeria: matters arising. Save the Children International Analysis;
Nigeria movement toward universal health coverage (UHC) is gaining momentum, with the Federal Government through the Ministry of Health appealing to states to scale up efforts to accelerate the transition toward universal access to affordable and quality health care services through domestication of National Health Act 2014 as many Nigerians still lacking access to essential health services—including childhood immunization and so on.
According to the outcome of 2016 Multiple Indicators Cluster Survey (MICS 2016) released by the National Primary Health Care Agency recently in Abuja, only one in three Nigerian children receive the mandatory three doses of pentavalent vaccine, 40% of Nigerian children do not receive any vaccines from the health system, 31% of those who received the first dose of pentavalent vaccine did not get three doses while only one in ten children of poorest families receive all three pentavalent doses.
Nigeria is among many under developed countries that largely depend on developed countries and international donors to finance immunization services for children under five and pregnant women through procurement and maintenance of vaccines/antigens, cold chain equipment and transportation of vaccines from country’s ports to the doorsteps of beneficiaries.
Although, some countries have started developing transition strategies of financing immunization from donor funding to domestic public financing sources and recognized as the financial foundation of universal health coverage, with immunization financing as an integral component.
Equally, innovative mechanisms such as health earmarks or basket or trust funds, where they exist, are likely to play strong coordination of immunization financing.
As some countries take on a greater role in financing their immunization programs and transition away from Global Alliance for Vaccines (Gavi) and other donor support, domestic public funding sources will play an increasingly important role in bridging the gap Domestic funding for health can come from public or private sources. Public sources include general revenue raised through broad-based taxes at the national or subnational levels and public insurance contributions.
Emergence of immunization basket funds in Nigeria
Zamfara State was the first state in Nigeria to introduce Immunization basket funds followed by Kano and Bauchi states respectively. Abasketfund is a promising mechanism of addressing many of these financing problems. In 2009, Zamfara State with support from defunctPartnership for Reviving Routine Immunisation in Northern Nigeria and Maternal Newborn and Child Health Initiative (PRRINN-MNCH), established the first basket fund in the country to improve routine immunization program and delivery. These resources are then directly disbursed to responsible officers for specific Primary Health Care activities such as immunization outreach and vaccine distribution to health facilities. Zamfara’s basket fund consists of government contributions (80%) and support from developmental partners (20%) for improving routine immunization. By pooling funds from the state’s 14 LGAs, the state government, and development partners, the state mobilised 1.5 million Naira and set up a state bank account with these funds in 2009. Each LGA has its own account in the same bank. Funds are disbursed directly to beneficiaries by finance officers; each invoice must be approved by representatives of the three funding agencies.
The basket fund has improved coordination of financing from different sources and raised the quality of data on immunisation. Routine immunisation coverage has increased with relatively minimal cost. As a result of significant changes recorded, the National Primary Health Care Agency directed other states of the federation to emulate Zamfara by coming up with their own pattern of pooling funds for immunization activities. States like Yobe, Kano, Katsina, Sokoto, and Niger have visited Zamfara for a learning study on the programme.
Why Basket Funds was started inZamfara?
In 2006, Nigeria’s immunization coverage rate for children was very low with only 42% of the target children fully immunized, while Zamfara state was ranked the last among 36 states with only 11% of target children were fully immunized withDiphtheria-tetanus-pertussis (DTP3). Absence of guaranteed funding to finance critical recurrent activities is consistently cited as a key challenge for Primary Health Care services, particularly routine immunisation in Zamfara. Equally, the coverage of routine immunization services was very low in the state as at 2008/2009.
This informed critical actors under the leadership of the state government through State Ministry of Health, State Ministry of Local Government and Chieftaincy Affairs, Association of Local Governments of Nigeria State chapter, and PRRINN –MNCH project to organized stakeholders meeting where factors associated with poor routine immunization coverage across the state were identified. These include; inadequate/lack fund even though LGAs authority maintained that funds were always given to the Primary Health Care department, lack of proper utilization of released funds was an issue, as well as challenges with coordinating the different sources of funding for routine immunization from development partners working on routine immunization in the state; WHO, UNICEF, PRRINN-MNCH, EU PRIME, etc.
It is exactly eight years now after the introduction of sustainable immunization financing by Zamfara State government popularly known as ‘Zamfara Routine Immunization Basket Funds’. The funding system has been a model to many states of the federation and some countries in Africa. The introduction of the basket fund by Zamfara State has significantly improved the delivery of routine immunization services and Immunization Plus Days (IPDs) for Polio Eradication.
Expanding basket funds to cover other primary health services
In 2013, UNICEF and Save the Children International held a high level advocacy meeting with Zamfara state basket funds stakeholders with aimed at expanding the programme to cover nutrition activities and complement development partners’ intervention on Community Management for Acute Malnutrition (CMAM) and MNCH-Week programme. At the meeting, 14 LGAs council chairmen approved N1,428,000,00 as their monthly contribution for the two programmes.
The ultimate purpose of the fund is to improve PHC services delivery; initially it was started to fund Routine immunization and Anti Natal Care services. Subsequently, supplemental immunization was added and other services have been added gradually such as funding for Midwives Service Scheme, Community Midwives programs, and Foundation Year Programme for Students of State School of Nursing and Midwifery as part of measures to sustain Women for Health (W4H). W4H is a DFID-funded project in the state.
SUSTAINABILITY OF BASKET FUNDS
One of the common questions asked by local and foreign partners about basket funds programme in Zamfara was around the measures put in place to ensure its sustainability especially due to changes in government.
In 2015, Save the Children through the Anchor Advocacy Project supported to the Zamfara State Ministry of Health to pursue the sustainability of the Basket Fund Scheme and this led to the development of the Primary Health Care Basket Fund bill.
It is a pooling system in which 70% of the total funds are contributed by the 14 Local Government Councils and 30%, by the State Government. Source of the fund as well asgrants, donations from any person, private or public organization, international community.
Save the Children advocated to the 14 LGA chairmen to review their monthly contributions by over 68% from NGN218000 to NGN368000 each in order to reach children in underserved communities with routine immunization services. Save the children also sponsored the production of copies of the bill that was shared to all the members of the State House of Assembly. Currently, the bill has passed the first and second reading. Advocacy efforts are ongoing to ensure that the bill is passed before the end of 2017.
Similarly, in 2017, Save the Children organized two days sensitization meeting for 14 LGAs chairmen and other critical actors on ring-fenced immunization financing. The objective of the meeting was to educate participants on the benefit associated with pooling of funds for immunization activities, to strengthen necessary machineries that will contribute to expand immunization services particularly outreach services to ensure women and children leaving in underserved and marginalized communities are reach and immunized and request for upward review of LGAs contribution to fill-in emerging funding gaps for Routine Immunization activities.
After an extensive deliberation on the successes and challenges of routine immunization through the state basket funds, participants noted the following issues:
Non-release of State Government contribution (20% of the total sum) to the State Basket funds amounting to over N112 million between 2009 – October 2017; Deplorable condition of health facilities and inadequate professional health workers at various health facilities; Non-implementation of 30% (N65,000) increased of LGAs monthly contribution for routine immunization intervention through the state basket funds as agreed on 9th November, 2015; and the non-absorption of 98 Community Midwife graduates.
Some of the reasons highlighted by Save the Children for mobilization of additional funds to strengthen immunization services in Zamfara includes; The existing contribution by LGAs into the funds was based on 2009 estimates which has become insufficient due to inflation, there is increase of additional health facilities from the initial 420 (2009) to all the 666 health facilities currently providing routine immunization services, there is population increase of target beneficiaries from 2009 to date and there was new vaccines that were introduced between 2009 to 2017
At the end of the meeting, participants observed that there is need to follow up with the state government for the release of its outstanding commitment (20% contribution) in view of the potential to save lives of children under five years, pregnant women and underserved communities, and a very good value for money. Equally, the following were agreed;
ü Formation of a nine member high level committee headed by the Commissioner for Local Governments and Chieftaincy Affairs, to meet with the Governor to facilitate the release of the Zamfara State Government contribution into the Basket Funds amounting to N112million between 2009 to October 2017.
ü Subject to the outcome of the above committee’s meeting with the Governor, the 14 LGAs agreed to meet and take final decision on additional financing to routine immunization programme,
ü Honorable Commissioner for local governments to develop and submit memo to His Excellency for his approval for the full absorption of 98 community midwifery graduates indigenes of the state,
ü Policy makers and other participants of the meeting applauded the effort and contribution of Save the Children International through Bill and Melinda Gates Foundation Advocacy project for providing technical supports and hosting series of meetings towards the sustainability of Basket funds in Zamfara state
It is also important to note that, a recent analysis found that every dollar spent on expanding access to a portfolio of vaccines in low- and middle-income countries between 2011 and 2020 would return $16 in economic benefits. Vaccines can save millions of lives and bring many other benefits, including healthier children, increased school attendance, and increased productivity. Immunization services are also a cornerstone of primary health care and can serve as a foundation for other vital health services. Immunization is an exceptionally good value, returning many dollars in economic benefits for every dollar spent.
Highlights of Zamfara Basket funds bill
I. There is hereby established a fund in the State to be known as primary Health Care Basket Fund. In this Law referred to as Basket Fund. Which shall be managed by the Technical Committee, Established under section 6 of this Law.
II. The Basket Fund shall be a body corporate with perpetual succession and a common seal.
III. The committee members shall be person of proven intergrity and to be appointed by the Governor Subject to the recommendation of the Ministry of Health
IV. The technical committee shall consist of the following:
(a) Hon. Commissioner Ministry for Local Government & Chieftaincy Affairs or his representative as chairman.
(b) Representative of the Ministry of Health.
(c) Three representative from NGOs Group.
(d) Ministry of Finance
(e) Ministry of Budget and Economic Planning.
(f) Chairman House Committee on Health
(g) Chairman ALGON
Subject to the provision of this Law, the technical committee shall perform the following functions in the discharge of its duties;
(a) Management and General Coordination of the Primary Health Care Basket Fund Programmes.
(b) Monitor and ensure collection and lodgment of Basket Fund from the donors/contributors.
(c) Liaise with Ministry for Local Government for the Lodgment and safe keeping of the funds.
(d) To ensure disbursement of the Funds to the various Primary Health care in the State.
(e) To regulate the Administration, application and disbursement of monies from the Basket Funds to the areas identified.
(f) To make and issue guidelines from time to time on the Basket Fund programme in the Areas of Routine immunization, maternal health etc.
(g) Monitor and evaluate execution of the Basket Fund projects.
(h) Do such other things as are necessary or expedient for the smooth operation of the Basket Fund Programme
The technical committee for the purpose of discharging its functions shall have power to
(a) Receive on behalf of the Basket Fund such money, stocks, pledges, promissory note, equipment any endowment from any person or company or International organization for the purpose of promoting Primary Health Care Programme.
(b) Accept donations in such appropriate case and at the request of the donor such donation shall be utilized according to specific wish of the donor.
(c) Make payments or disbursements from money collected for the fund to meet specific expenses in respect of the day to day administration of the funds as approved by the technical committee.
(d) Pay cost and expenses of or incidental to the management of the fund as approved by the technical committee.
The source of funds of the Basketfundsshall be by way of grants, donations from any person, private or public organization, international community or contribution from the State Government, Local Government and the development partners
For the purpose of this Law all cheques or instruments, for withdrawal of any amount of money from the account of the Basket Fund most carry the signatures of the Permanent Secretary Ministry for Local Government and Chieftaincy Affairs, Director Primary Health Care Ministry of Health one of the Development partners.
(2) The Fund shall not in any case be withdrawn without the three signatories of the officers mentioned in subsection 1 of this section.
Punishment; Any person who contravene the provisions of this law or dishonesty misappropriates the Basket Fund Or dishonesty diverts or fails to remit any amount meant for the Basket Fund or Embezzles any money meant of the Basket Fund Programme commit an offence and shall be liable for on conviction to a fine of 50,000 only or imprisonment of three years or both.
SUCCESS OF BASKET FUNDS IN ZAMFARA
Firstly, the introduction of the basket fund by Zamfara State with full support of LGA Chairmen has significantly improved the delivery of routine immunization services, IPDs for Polio Eradication and some Nutrition activities. Secondly, through the introduction of Basket fund, Zamfara State was able to reduced transmission of polio since 2009, and has been Wild Polio Virus free since June 2012. Thirdly, the number of un-immunized children has drastically reduced in Zamfara State. Fourthly, the burden of VPDs and of malnutrition drastically reduced. And based on all these facts, Zamfara State Government had earned global recognition by adopting the basket fund which facilitated the winning of the Bill & Melinda Gates Leadership award on immunization in 2012, Dangote and Bill and Melinda Gates Foundation in 2014 amounting to $1million respectively.
LESSONS from Zamfara Basket funds
Working with local government councils and state ministry for local government provides greater opportunity to mobilize and secure sustainable funds for primary health care services
It provides a platform for a transparent fund disbursement and utilization mechanism and promotes coordinated financing of interventions
Removes duplicate funding of same activities by different funding sources e.g. funds from GAVI meant for RI activities are channeled into the fund and avoids double funding of same activity
Challenges of basket funds implementation
One of the major challenges experienced by the Zamfara state government on basket funds introduction and implementation was meeting the financial guidelines of Partners which limits the ability of the partners to contribute, and Managing huge expectations from the fund; many other interventions wants to be funded by the fund but resources are limited e.g. outbreaks, trainings etc.