Community Engagement Strategy for Strengthening Routine Immunization in Northern Nigeria

"Improving collaboration with communities requires a well-defined strategy that utilizes the traditional architecture of the community."

Community engagement (CE) is the process by which the health system works collaboratively with host communities to improve community ownership of health and health programmes to address both supply and demand-side factors that contribute to poor programme performance and health indices in the community. In Nigeria, over 40% of under-5 mortality in Nigeria is due to vaccine preventable diseases (VPDs), a problem that is driven in large part by consistently low immunisation coverage rates and weak health systems. This strategy document from Nigeria's National Emergency Routine Immunization Coordination Center (NERICC) and National Primary Health Care Development Agency (NPHCDA) explores ways to support communities in taking the lead in identifying, owning, and resolving issues that contribute to low or stagnating immunisation rates in Nigeria.

NERICC and NPHCDA explain that community-related causes of low demand include: poor community involvement in planning and implementation of routine immunisation (RI) services, social and cultural barriers to access (lack of knowledge about potential benefits of vaccinations), lack of accountability and a weak governance system for RI, poor service delivery, missed opportunities at health facilities, and weak sustainability of planned interventions.

In Northern Nigeria, the community has a traditional architecture that is well known and could be harnessed for coordination and mobilisation of communities for action. The Global Polio Eradication Initiative (GPEI) used this community architecture with recorded success, and the Expanded Program on Immunization (EPI) is using this architecture in the form of Ward Development Committees (WDCs) and Village Development Committees (VDCs) and in the development of microplans for both routine and supplemental immunisation activities. Some Northern states have also developed state-specific CE strategies, which the leadership of the Northern Leaders Traditional Council, the Sultanate, and some Emirate Councils are working to harmonise within a coordinated framework.

This strategy builds on these models with the goal of:

• Increasing participation of the community in planning for immunisation services as a means of facilitating vaccine uptake and community herd immunity;
• Providing specific support to ensure community ownership of RI services through traditional structures and leadership in identified high-priority states in Northern Nigeria;
• Improving RI performance in low-performing local government areas (LGAs) by conducting community referrals and defaulter tracking, improving compliance, and reducing missed opportunities for immunisation; and
• Increasing and sustaining community demand for RI.

Central to this strategy are the key roles played by all stakeholders in facilitating improved outreach and increased number of children immunised through fixed post sessions. (See Table 1 on page 4.) Steps are detailed in the document and include tracking of newborns (engaging community volunteers and Mai Unguwas, who are the heads of settlements and communities within the traditional institution); reconciling of records (involving the Community Engagement Focal Person - CEFP); and data reporting and management (involving, e.g., the village head and the district head).

The CE strategy incorporates revised child health cards with a triplicate tear off portion: A copy of the tear-off portion is to be kept by the health facility (HF) (to aid defaulter tracking), a copy is to be given to the traditional ruler during weekly reconciliation meetings, and the original goes to the child's caregiver. Advocacy to traditional leaders/religious leaders/key influencers entails inquiry about child health cards during the christening/naming of the newborn or upon first contact with the baby. For instance, the Cleric asks to see the child's card prior to christening/the naming ceremony to ascertain that the child has received the birth vaccination doses. Where this has not happened, the cleric will encourage the child's caregiver to get the child immunised immediately.

Principal steps in setting up and implementing the CE strategy in a State/LGA/Community are outlined and include, in brief: Conduct community diagnosis; conduct stakeholder engagements; conduct trainings for all cadres of stakeholders at respective levels; implement the strategy in line with a defined implementation plan; and monitor, evaluate, and re-strategise.

The standard operating protocol (SOP) included in the document provides guidelines on roles and responsibilities of particular participants in the CE strategy. Specific indicators have been developed to be tracked within the traditional architecture; see page 14. Annexes include data tools (reporting forms).