Access to Routine Immunization: A Comparative Analysis of Supply-Side Disparities between Northern and Southern Nigeria

Friday, 8th of January 2016

Access to Routine Immunization: A Comparative Analysis of Supply-Side Disparities between Northern and Southern Nigeria

Ejemai Eboreime,
Seye Abimbola,
Fiammetta Bozzani

Abstract below; full text is at http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0144876

Background

The available data on routine immunization in Nigeria show a disparity in coverage between Northern and Southern Nigeria, with the former performing worse. The effect of socio-cultural differences on health-seeking behaviour has been identified in the literature as the main cause of the disparity. Our study analyses the role of supply-side determinants, particularly access to services, in causing these disparities.

Methods

Using routine government data, we compared supply-side determinants of access in two Northern states with two Southern states. The states were identified using criteria-based purposive selection such that the comparisons were made between a low-coverage state in the South and a low-coverage state in the North as well as between a high-coverage state in the South and a high-coverage state in the North.

Results

Human resources and commodities at routine immunization service delivery points were generally insufficient for service delivery in both geographical regions. While disparities were evident between individual states irrespective of regional location, compared to the South, residents in Northern Nigeria were more likely to have vaccination service delivery points located within a 5km radius of their settlements.

Conclusion

Our findings suggest that regional supply-side disparities are not apparent, reinforcing the earlier reported socio-cultural explanations for disparities in routine immunization service uptake between Northern and Southern Nigeria. Nonetheless, improving routine immunisation coverage services require that there are available human resources and that health facilities are equitably distributed.

Citation: Eboreime E, Abimbola S, Bozzani F (2015) Access to Routine Immunization: A Comparative Analysis of Supply-Side Disparities between Northern and Southern Nigeria. PLoS ONE 10(12): e0144876. doi:10.1371/journal.pone.0144876

Editor: Umberto Simeoni, Centre Hospitalier Universitaire Vaudois, FRANCE

Received: May 30, 2015; Accepted: November 24, 2015; Published: December 21, 2015

Copyright: © 2015 Eboreime et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Data Availability: This study is based on data routinely collected in the Nigerian public health sector, most of which are publically available. Some data were accessed from the National Health Management Information System available online atwww.dhis2nigeria.org.ng. Data not in the public domain were made available by the Federal Ministry of Health (FMOH) and the National PHC Development Agency (NPHCDA) upon request. These include data from Nigerias PHC reviews. Although two of the authors (EE and SA) were part of the designing and coordination of the reviews, the data is owned by the Government of Nigeria and under the custody of the FMOH and NPHCDA. Future researchers may contact the NPHCDA via info@nphcda.gov.ngor the website www.nphcda.gov.ng for information on access to the data.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Ever since the demonstration of the value of immunization by Edward Jenner in 1792, vaccination has increasingly become a key strategy in the prevention and control of infectious diseases globally. Nigeria, with a population of over 170 million, has one of the highest under five mortality rates in the world (143 deaths per 1000 live births), with about 25% of these deaths preventable through routine immunization [1]. Available data for routine immunization show a disparity in coverage between Northern and Southern Nigeria. National surveys reveal that, compared to the South, Northern Nigeria performs poorly on health indices, including immunization coverage[2]. Previous studies show that children in parts of Southern Nigeria have more than twice the chances of receiving full immunization compared to children in parts of Northern Nigeria [3].

Nigeria is comprised of 37 states (inclusive of the Federal Capital Territory) which in turn comprise a total of 774 Local Government Areas (LGAs). The constitution of Nigeria creates a considerably decentralised system of government (politically and fiscally) in which health is the concurrent responsibility of the federal, state and local tiers of government [4, 5]. The federal government develops policies and guidelines, provides technical support and is responsible for the delivery of tertiary health care, while secondary and primary health care (PHC) are under the purview of the states and local governments, respectively. In relation to immunisation, the federal government purchases vaccines, develops immunisation guidelines and provides technical support to sub-national governments through the National PHC Development Agency. However, states and local governments provide infrastructure and logistics to deliver routine immunization services. The policy of the government of Nigeria is to “provide immunization services and potent vaccines free to all population at risk” [6]. And to ensure equitable access, the federal government recommends having routine immunisation services available within 5km of any community [6, 7]. However, a 2013 survey found that immunisation coverage in Northern Nigeria zones ranged from 14% to 44%, while in Southern Nigeria zones, the range was 70% to 81% [2].

Northern Nigeria, which is predominantly Islamic, bears cultural semblance to the Arab states of North Africa and the Middle East [8, 9]. Although diverse in ethnicity, the Hausa and Fulani (a largely nomadic group) cultures predominate. Historically, Northern Nigeria is divided into Emirates, which are ruled by Fulani Emirs to whom minority groups paid tributes and from whom religious and social norms derive. Islamic education is still widespread in northern Nigeria [10]. Southern Nigeria on the other hand, with its numerous ethnic groups (the largest being the Yoruba, Igbo and Ijaw), has Christianity as its dominant religion. Southern Nigerians tend to embrace Western culture and education as a consequence of direct British colonial rule [8, 9]. Studies document the impact of these socio-political and ethno-religious diversities on health disparities, through their effect on health-seeking behaviour and other demand-side factors [3, 11]. Although little is known about regional disparities in supply-side determinants, researchers and policymakers have established and focussed on the association between demand-side factors and immunisation coverage. This evidence and focus has led to interventions such as education (including maternal education), advocacy and community mobilization as a means of addressing inequities in utilization of routine immunisation services [1, 3, 11]. In this study, we sought to examine the contribution of supply-side issues to inequities in routine immunization services between Northern and Southern Nigeria. Our study hypothesis is that regional variations in vaccination uptake are not exclusively explained by the socioeconomic and cultural differences between the regions, but can also be attributed to supply-side determinants. We are thus looking at differences between high- and low-coverage states in the same region, where demand-side determinants are similar, to assess whether the same inequalities in access are uniformly present in the North and in the South.