In the past few years, Nigeria has successfully expanded access to life-saving vaccines and entered the last stages of pushing polio to the brink of eradication. As Commissioner for Health of Kano State, I take great pride in these advancements. But I also view them with equanimity.
Our country continues to face immunization challenges, common in sub-Saharan Africa. These challenges must be overcome in order to deliver vaccines to the last mile. Two challenges of note include recurrent vaccine stock-outs and suboptimal data to track supply.
Following a national level stock-out in 2011 that had ramifications in Kano and other states, the Bill & Melinda Gates Foundation (BMGF) partnered with Kano State in 2012 to survey our existing vaccine supply chain model. At the time, our system relied on health officers to track stock and collect (“pull”) vaccines from higher levels on an “as-needed” basis. Unfortunately, this system was labor intensive, saddled health workers with costs, and collected inadequate data to accurately plan routine immunization activities in health facilities and outreach sites.
After several planning discussions, we in Kano State partnered with BMGF and the Dangote Foundation in late 2012 to kick-start a 3-year agreement specifically designed to strengthen our routine immunization program, starting with a focus on addressing the stock-out and data tracking issues. The ‘informed push’ approach developed for improving how vaccines get delivered and tracked is called Push Plus.
Here is how it works: vaccines begin their journey at a single state store. They are then delivered to six satellite stores on a monthly basis, followed by delivery to at least one “apex facility” among the local ward’s health facilities. The apex health facility is equipped with solar refrigerators for storage and maintenance of vaccines at optimum temperature. Along the way, a mix of trucks owned and managed by Kano’s State Primary Health Care Management Board and those operated by private vendor eHealth Africa carry out the deliveries. Finally, vaccines from the apex facilities are delivered to facilities unequipped with solar refrigerators in the local ward, via public transportation or motorbike. Data on the vaccine stock down to the equipped facilities is reported to the State each week—giving visibility at a level that has never been available before. This visibility enables us to track vaccine availability and identify where more vaccines may need to be pushed.
By “pushing” vaccines down the entire supply chain on a routine schedule, Push Plus has proven to be a huge benefit for Kano State. Stock-out rates across 484 wards of the 44 Local Government Areas fell from 41% to 3% between 2014 and 2016. More than 75% of planned deliveries are executed on schedule. And we now have weekly in-depth data dashboards to track vaccine supply with pin-point accuracy.
These represent critical supply side improvements—and they are being met with equally important efforts now underway to improve service quality, build trust, and help increase awareness and demand among families with young children in need of vaccines.
Though routine immunization in Nigeria continues to face unique challenges, Kano State’s implementation of the Push Plus vaccine delivery approach is helping to turn the tide. Critical to our success has been the full engagement and commitment of Kano State decision makers. The focus on revitalizing immunization has been through our State Primary Health Care Management Board—led by the Executive Secretary Dr. Nasir Mahmoud and his immunization team. Our State Logistics Officer, Pharmacist Rabiu Fagge, has led the Push Plus work, with great support from members of the State Logistics Working Group and others. The Kano Emergency Operations Center, led by the Incident Manager Dr. Imam Wada Bello, provides polio eradication-focused support to the state. And the polio campaigns that it runs work hand-in-hand with the state team that manages the Push Plus system for routine immunization.
Their leadership has shown how much we can accomplish by working together—and this success has lit a path for others. Kano State has also been working very closely with the National Primary Health Care Development Agency’s Department of Logistics and Health Commodities and partners to share experiences and ensure that all approaches are in line with federal strategies. In addition to Kano State, five other states are now implementing Push Plus, and 10 additional states in Nigeria are currently in the planning stages.
This post was co-authored by Dr. Mohammad Nasir Mahmoud, Executive Secretary, Kano State Primary Health Care Management Board; Dr. Imam Wada Bello, Incident Manager, Kano State Emergency Operations Center; and Pharmacist Rabiu Fagge, Kano State Logistics Officer.