Nigeria’s COVID-19 Vaccine Rollout: Expectations vs. Reality

Dr. Cyprian Ngong, a staff member of National Hospital, Abuja, receives COVID-19 vaccine.

On March 02 2021, Nigeria received almost 4 million doses of the Oxford-AstraZeneca COVID-19 vaccine. Since then over one million Nigerians have received their first dose of the vaccine according to the National Primary Health Care Development Agency (NPHCDA). This article aims to assess how the COVID-19 vaccine rollout has been handled in Nigeria, particularly in comparison to the key hypotheses in my article published by Helium Health prior to Nigeria receiving the first batch of vaccines.

Hypothesis #1: Nigeria will get its COVID-19 vaccines via the WHO ACT and COVAX GAVI Initiatives

The article hypothesized that the Nigerian government will secure vaccines through the WHO’s Access to COVID-19 Tools Accelerator (ACT) and the COVAX Facility. The WHO ACT is a global mechanism tracking and sponsoring global organizations working on COVID-19 vaccine development, while the COVAX Facility is a Gavi-sponsored initiative to ensure equitable access to vaccines as soon as they are available, especially for lower-income countries. 

Reality: In March 2021, Nigeria received 3.94 million doses of the Oxford-AstraZeneca vaccine that were manufactured in India and shipped through the COVAX initiative, making it the third West African country to receive vaccines through this initiative, after Ghana and Ivory Coast. This represents the first shipment of over 16 million doses allocated to Nigeria through this initiative, with the goal of vaccinating at least 40% of the population by the end of 2021. 

The National Agency for Food and Drug Administration and Control (NAFDAC) approved the use of the Oxford-AstraZeneca vaccine in February 2021, allowing for the immediate rollout and delivery of vaccines when they arrived. Despite the safety concerns, the Oxford-AstraZeneca vaccine potentially represents the most feasible logistical option for Nigeria given that it can be kept in normal refrigerated conditions, compared to the Pfizer vaccine which requires -70º storage. 

While the government has secured private sector services for the provision of ultra cold vaccine storage facilities, minimizing the logistical burden is crucial to ensure a speedy and efficient rollout given the power supply shortages and poor infrastructure across primary health care facilities in the country. As such, the one-shot Johnson & Johnson vaccine could represent another logistically favorable option for the country given the lack of additional resources required to secure a second dose for full immunization. The Nigerian government hopes to receive roughly 70 million doses of the Johnson & Johnson vaccine through the African Union this year.

Hypothesis #2: The National Primary Health Care Development Agency (NPHCDA) will handle the distribution and delivery of the COVID-19 vaccines in Nigeria

Based on an announcement from Chikwe Ihekweazu, the Director General of the Nigeria Center for Disease Control (NCDC), the original article indicated that the NPHCDA would lead the distribution and planning of a COVID-19 vaccine in Nigeria. 

The NPHCDA is significantly involved in the repairing of Nigeria’s Primary Healthcare System, receiving approximately 45% of the Basic Health Care Provision Fund (BHCF) to procure essential drugs, maintain primary health care facilities, equipment and transportation and improve human resource capacity. However, the article expressed concerns about the ability of the NPHCDA to effectively manage the COVID-19 vaccine rollout, particularly as the BHCF is funded using only 1% of federal revenue, and poor data management and accountability may hinder the impact of this initiative.

Reality: On March 07, 2021, the NPHCDA, in collaboration with the Federal Ministry of Health, kicked off the national COVID-19 vaccination campaign at the National Hospital in Abuja. Since then, the NPHCDA has been overseeing and monitoring the delivery of the Oxford-AstraZeneca vaccine through a large network of primary health care facilities across all 36 states and the Federal Capital Territory (FCT).

On April 28, 2021, the NPHCDA reported that 1,191,563 eligible Nigerians had been vaccinated with the first dose of the COVID-19 vaccine. Lagos, Kaduna and Kano states have administered the largest number of vaccines with 231,377 (Lagos), 62,157 (Kaduna) and 61,221 (Kano) doses administered in each state. However, there are a few states that have relatively low population-adjusted vaccine uptake rates - Anambra state, for instance, is one of the most populous states in the country and yet has only delivered ~12,700 COVID-19 doses as of April 28.

This discrepancy is further exacerbated when we examine the data as a percentage of the total eligible people targeted for vaccination in each state in the current phase of the rollout. Kwara state has exceeded its target at 112%, while Anambra, Sokoto and Taraba states have only reached about a third of their targets.

As Nigeria approaches half of the 3.94 million Oxford-AstraZeneca vaccine doses it received, the data point to a somewhat inequitable rollout of the COVID-19 vaccines across primary health care centers in the country. Primary health care is mainly funded and provided by local governments and there are significant differences in funding across Local Government Areas (LGAs) in the country. As such, this discrepancy could represent the funding gaps that are preventing certain vaccination centers from operating at full capacity.

The vaccine delivery discrepancy could also represent the widespread anti-vaccination sentiment across the country, particularly in rural areas or areas with low literacy rates. In an effort to encourage uptake of the vaccines among the largely skeptical Nigerian population, the NPHCDA recently partnered with Facebook to launch a COVID-19 vaccination awareness campaign on social media.

Hypothesis #3: The Nigerian government will prioritize high risk groups and healthcare workers first for the vaccine

Reality: According to the NPHCDA, the COVID-19 vaccine will be rolled out in four phases. Nigeria is still in Phase 1 of the rollout, which prioritizes health workers, supporting staff, frontline workers and first responders. Phase 2 will prioritize individuals that are 50 years and above, starting with those that are 60 years and above. Phase 3 will prioritize those 18-49 years old with co-morbidities (defined by pre-existing conditions such as obesity, diabetes, chronic kidney, respiratory, cardiovascular and other diseases as identified by their doctors) and Phase 4 will open up vaccines to the rest of the eligible population between 18-49 years.

For the first phase of the rollout, registration for vaccination appointments is available through an online platform. However, an online registration process may not be entirely conducive to an equitable rollout, particularly as only 46.6% of the population have access to the internet - this could significantly delay the vaccinations of Nigerians that do not have internet access, particularly the elderly and those in low-income households.

Additionally, the online platform currently does not include a list of documentation required to prove eligibility at the vaccination appointment (e.g., employment identification, doctor’s letter, etc.), which opens the floodgates for several ineligible citizens to receive the vaccine. This has reduced the available supplies left for eligible citizens that are at high risk of infection and led to long wait times at vaccination centers. The NPHCDA said that its approach to the vaccine rollout also includes assisted (i.e. house-to-house) electronic registration for health workers with “lack of Android devices and poor network”; however, there is limited publicly available information about this approach. Other African countries have employed a hybrid approach to ensure an equitable rollout - for example, in Ghana, mobile vaccination teams reached elderly people in remote communities with the help of community organizers.

Recently, in an effort to meet domestic demand amidst a massive COVID-19 surge, India put a temporary hold on all major exports of the vaccines manufactured by the Serum Institute of India. On April 7 2021, Dr. Osagie Ohanire, the Federal Minister of Health, reactively issued a directive to all 36 states and the FCT to stop administering first doses of the vaccine once half of their current stock is depleted to safeguard supply for the second dose until more vaccines are procured. As a result, on April 22 2021, Lagos State shut down its COVID-19 vaccination centers after administering over 200,000 first doses. This MoH directive further limits supplies of the vaccine for high risk citizens until the supply chain issues are resolved.

Key Takeaways from TC Health: In order to allow for equitable access to vaccines, the Nigerian government should ensure that local governments and primary health care facilities are well-equipped and adequately funded to handle the volume of vaccines required to hit their targets during each phase of the rollout. Vaccination appointment registration should be made available via phone or at select in-person registration centers to allow access to registration for people with no internet access, particularly the elderly and those in low-income households. The registration portal should track and enforce eligibility criteria to allow more people that are most in need of vaccines to get them first before supplies run low. 

To encourage widespread uptake of the vaccines, the Nigerian government should publish an official rollout strategy document and launch a nationwide public health education campaign to dispel widespread skepticism of vaccines in the country and encourage adoption. Lastly, with a population of over 200 million people, Nigeria needs more vaccines, plain and simple. The Nigerian government should continue to work with global vaccine initiatives and manufacturers and secure private sector assistance to procure as many vaccines as possible, particularly given the recent supply chain issues.