Gavi support to vaccination in Nigeria

Author:

Ida Hakizinka and Maryline Mireku

Article Type:

Article Number: 7

Gavi support is strengthening Nigeria’s in-country systems for sustainable immunization programmes

The article covers Gavi’s partnership's focus on strengthening in-country systems in Nigeria for better financial management, accountability, and achieved milestones. We also highlight the significance of local government commitment, technical assistance, aligned objectives, and partnerships with other development organizations for sustainable outcomes in the health sector.

Background 

Gavi, the Vaccine Alliance, has been at the forefront of providing financial and technical support to countries worldwide, aiming to strengthen their immunization programs. Gavi’s support for countries includes health system strengthening, vaccine procurement and delivery assistance, optimization of cold chain equipment, and targeted country assistance through partners. By investing in health system infrastructure, securing affordable vaccines, optimizing cold chain systems, and addressing specific immunization challenges, Gavi aims to achieve sustainable improvements in immunization programs, ensuring that more people have access to vaccines and reducing disparities in coverage and outcomes.

Recognizing the importance of sustainable immunization financing, Gavi has developed an Aid transition plan that empowers countries to gradually reduce their reliance on Gavi while strengthening their resources and immunization systems. The plan comprises four interconnected phases facilitating a smooth transition for countries, as illustrated in Figure 1 below.

The plan acknowledges the need for countries to take ownership of their immunization program and gradually assume a larger financial responsibility. Under the plan, Gavi works closely with governments and other partners to develop strategies that facilitate a smooth transition. Gavi uses Gross National Income (GNI) to determine eligibility for support. Gavi updates the eligibility threshold support for countries annually and sets it at $1,730 GNI per capita in 2023 for its planning purposes.

Under the Gavi policy, countries are classified by one of three phases: initial self-financing, preparatory, and accelerated transition. The initial self-financing phase applies to countries with GNI below the low-income threshold, currently those with a GNI of $1,085. The preparatory transition phase is for countries above this threshold. The accelerated transition phase starts when a country’s three-year average and most recent GNI exceed the eligibility threshold and the country is able to co-finance at least 35% of vaccine costs. This phase lasts up to eight years, and during this period the country can still apply for new vaccine support. After completing the accelerated transition phase, countries are deemed to become fully self-financing.

Gavi’s support for Nigeria’s vaccination program

Gavi support in Nigeria dates from 2001 when the country became eligible for Gavi funding. Over the years, Gavi has provided substantial financial assistance to Nigeria’s vaccination programs of over $7 billion. Originally, Nigeria was scheduled to graduate from Gavi support in 2021. However, the country was unable to shoulder the vaccination program’s costs, hence Gavi granted Nigeria an extension.

The new agreement involves a significant investment of $2.7 billion, with Gavi contributing $1.03 billion and Nigeria providing over $1.9 billion. This investment aims to save the lives of 1,539,651 children under the age of one by 2028, making it Nigeria’s largest health sector investment. Its objectives include increasing immunization rates, improving the vaccine supply chain, restoring financial credibility, revitalizing the primary health care (PHC) system, and consolidating efforts in polio eradication. Ultimately, this investment will lead to improved improve healthcare service and save Nigerian lives.

The Nigeria National Primary Health Care Development Agency (NPHCDA), a parastatal of the Federal Ministry of Health, is responsible for providing technical support to subnational governments to smoothly implement PHC services. Previously, funding for Gavi activities at both the national and state levels was overseen by the NPHCDA.

However, a 2014 Gavi audit report for Nigeria revealed misappropriation of funds amounting to $2.2 million during the fiscal years 2011-2013. The audit report covered expenditures and procurement activities conducted by the Federal Ministry of Health, NPHCDA, and various States. In accordance with the joint letter of understanding and the Partnership Framework Agreement (PFA) between Gavi and Nigeria, which was co-signed by the Minister of Health, Minister of Finance, and Gavi’s CEO, Gavi requested that Nigeria return the funds. Gavi has since been fully reimbursed.

To address past audit issues, Gavi decided to temporarily avoid direct resource allocation through Government systems. Instead, Gavi introduced principles of engagement for Nigeria that required the Government to demonstrate specific commitments. These commitments included, as well as reimbursing misused funds, increasing health budget allocations on a yearly basis, ensuring programmatic equity in low coverage areas, implementing robust monitoring and evaluation practices, and showcasing the effective transitioning of polio eradication resources. Gavi made it clear that non-compliance with these principles would result in a lack of further support.

With support from Gavi and its partners, Nigeria’s Government developed the Nigeria Strategy for Routine Immunization and Primary Health Care Systems Strengthening (NSIPSS). The NSIPSS has an accountability framework to showcase the Government’s dedication to financial and programmatic accountability. This framework consists of key indicators for accountability and outlines expected rewards and sanctions based on the aforementioned principles of engagement. The aim is to ensure transparency, responsibility, and effectiveness in the utilization of resources and program implementation.

In line with the principles of engagement, Gavi acknowledged the significance of long-term capacity building in financial management at the national and selected State levels. With the objective of transitioning towards sustainable fiscal management, Gavi agreed to support the development of financial management capabilities through. collaboration between Gavi and the NPHCDA to address weaknesses and strengthen the system.

Gavi and Aidspan partner to strengthen national systems’ capacity for grant oversight

Aidspan is now able to take advantage of its existing project, building the capacity of Supreme Audit Institutions, to work with those in Nigeria to improve accountability and governance.

Supreme Audit Institutions (SAIs) are public oversight institutions responsible for providing government revenue and expenditure assurance. The Aidspan’s SAI capacity development project, initiated in 2018, aims to enhance financial, programmatic, procurement, and supply chain oversight for global health initiatives, which include programs supported by Gavi and the Global Fund. Aidspan is currently in the process of implementing the project’s third phase, which focuses on strengthening SAI and internal auditor capacity in the Democratic Republic of Congo (DRC), Malawi, Mozambique, Nigeria, Tanzania, Uganda, and Zimbabwe. This phase is supported by GIZ BACKUP Health, with funding from the German Federal Ministry of Economic Cooperation and Development (BMZ) and the United Kingdom’s Foreign, Commonwealth & Development Office (FCDO).

Gavi supports institutional capacity development for countries transitioning to fully self-financing their immunization programs. Gavi has a Transparency and Accountability Policy (TAP) that aims to ensure the transparent and accountable management of its support at the country level. The Policy sets minimum standards for using cash, vaccines, and vaccine devices, emphasizing proper financial and vaccine management systems, compliance with reporting requirements, and adherence to transparency and anti-corruption standards. It focuses on aid effectiveness, prevention of misuse, risk-based monitoring, flexibility, mutual accountability, and strengthening country systems.

As part of Gavi’s commitment to strengthening country systems and supporting institutional capacity development, Gavi is collaborating with Aidspan in its SAI capacity development project to equip SAIs and internal auditors in recipient countries with the knowledge and skills necessary to conduct comprehensive audits related to Gavi grants. The training aims to enhance oversight and transparency in the utilization of Gavi funds, supporting the success of immunization programs as countries progress towards self-financing. So far, 50 auditors from the SAIs of Malawi and Nigeria have been trained on auditing Gavi grants .

In Nigeria, Aidspan collaboratively organized with Gavi a five-day training in Abuja, held between 29 May and 2 June. It brought together auditors from the Office of the Auditor General for the Federation of Nigeria (OAuGF) and the NPHCD, creating a conducive environment for knowledge -haring and skill enhancement

A presentation by Cosmus Wahinya, a senior manager from Gavi, highlighted Gavi’s support to Nigeria and reported that, with Gavi’s financial and technical assistance, the NPHCDA had achieved significant milestones. This included the development of a Financial Management Capacity Building (FMCB) plan, the setting up of an enhanced Grants Coordination and Compliance Office, the development of donor financial management standard operating procedures, and the establishment of a computerized accounting system. Cosmus described Nigeria’s transition experience illustrated in Figure 3. Recognizing the high fiduciary risk associated with investing in Nigeria and the importance of ensuring effective fund allocation at the sub-national level, Gavi conducted a comprehensive Program Capacity Assessment (PCA). This played a crucial role in determining the most appropriate approach for resource allocation and identified Grant Management Requirements (GMRs) that needed to be implemented prior to disbursement of funds.

Gavi’s continued support and future plans in Nigeria

Following the Gavi board approval of the Financial Management and Risk Assurance fund in June 2021, Gavi stepped up its support to the NPHCDA. This included engaging service providers to address pre-disbursement conditions outlined in the GMRs. Technical support from these will continue until December 2023, overseen by the Portfolio Financial Management (PFM) team. Future steps include formalizing the GMR, engaging the services of an assurance provider to oversee the financial management of Gavi’s grants, continuing to build support at the State level, and finalizing banking arrangements.

Gavi’s TAP sets the context for fiduciary assurance in Nigeria to ensure that all Gavi support is used appropriately, managed transparently, and is supported by accurate and verifiable reports. Additionally, Gavi continues (PCAs on an ongoing basis to evaluate the systems and processes used to inform implementation and Nigeria’s journey towards transition.

To assist Nigeria’s self-sufficiency, Gavi works through country systems for optimal sustainability. This includes working with the SAI and the aforementioned assurance provider, as quality and timeliness of audits are critical elements. Through these strategies, Gavi is striving for comprehensive program assurance, going beyond mere compliance, to ensure that limited resources deliver value for money. Gavi’s continued support towards using Nigeria’s in-country accountability systems will not only contribute to the sustainability and effectiveness of immunization programs but also strengthen the overall health system, reducing risks and building local capacities to deliver primary health care.