World Health Organization's Innovative Direct Disbursement Mechanism for Payment of Grassroots Immunization Personnel and Operations in Nigeria: 2004–2015

Abstract

Background. Following the 1988 World Health Assembly resolution to eradicate polio, the government of Nigeria, with support from partners, has been implementing several rounds of supplementary immunization activities (SIAs) each year. In addition to the technical requirements, the success of the polio eradication initiative depends on timely provision of adequate financial resources. Disbursement of funds for SIAs and payment of allowances to numerous vaccination personnel at the grassroots level are enormous operational challenges in a country the size of Nigeria. Upon donors' request for a transparent and effective payment mechanism, the World Health Organization (WHO), in consultation with national counterparts, created the innovative direct disbursement mechanism (DDM) in 2004. The objective of the DDM was to timely deploy operational funds at the field level and directly pay vaccination personnel allowances at the grassroots level.Methods. A detailed operational guideline for funds disbursement was developed in close consultation with central and field stakeholders. Multiyear financial resource requirements and operational budgets for every campaign were produced by an interagency-coordinated finance subcommittee. The WHO engaged a bank and an accounting firm as DDM partners to support disbursement of and accounting for the SIA funds, respectively. The 37 WHO field offices were equipped with electronic financial systems to support the DDM process, and temporary payment sites were set up to facilitate payment to vaccination personnel at the grassroots level. Coordination meetings among DDM partners were held regularly to reconcile financial records and address operational challenges.Results. Between 2004 and 2014, DDM supported 99 polio and nonpolio vaccination campaigns, disbursing more than $370 million to about 16 million beneficiaries across 280 temporary payment sites. To mitigate security risks and reduce operational costs, the WHO and DDM partners introduced mobile payment to vaccination personnel in May 2015 in compliance with national regulations. A total of 97% of the targeted 1871 beneficiaries in 2 pilot sites were successfully paid through mobile payment, although some challenges remain to be addressed.Discussion. The DDM has met its objectives with a high rate of financial accountability and transparency, despite persistent operational and security challenges. With support from Nigeria, the Pakistan polio vaccination program successfully adopted the DDM. The DDM continues to play an important role in effective implementation of the polio endgame strategy and the national immunization strategic plan. As part of polio legacy planning, we recommend the DDM as a model for other opportunities that involve the engagement of large field-level teams as new vaccines are introduced in Nigeria and elsewhere.

Strengthening vaccination delivery system resilience in the context of protracted humanitarian crisis: a realist-informed systematic review

“…Availability of a partner bank in-country with capacity to support mobile phone-based funding disbursement important to intervention delivery. [ 53 ] Private sector engagement Transformative Statistically significant increase in coverage for selected antigens in intervention area by comparison with controls. Community-embeddedness of the intervention – through engagement of local councils – was important in supporting demand for vaccination through the public-private partnership.…”

“…The study on disbursement mechanisms did not consider any of our primary outcomes, but did address intermediate effects (secondary review outcomes) including successful completion of health worker payments, widely understood to be a key operational challenge for programme delivery in LMICs in general, and humanitarian settings in particular [ 53 ]. In this intervention, the WHO oversaw direct disbursement to the local level through a variety of activities including a newly introduced e-payment system, the establishment of close-to-facility payment sites and later the use of mobile payment systems, with reconciliation of funding distribution through partner meetings and other forms of information exchange.…”

“…These included two that looked at macro-level financing -specifically the value or otherwise of development aid in promoting improved health outcomes, including for vaccination, and system-strengthening in Gavi supported countries [55,56]; one study that considered private sector provider engagement in RI provision [54]; and four that considered in one way or another improvements to local level incentives for vaccination delivery [50][51][52][53]. Of these four, three studies considered explicit incentivisation to facilities or health workers via pay for performance (P4P) [50][51][52]; and one considered improvements to disbursement of programme funds to local level to promote vaccination delivery as a means of reducing the risk of delayed payment to healthcare workers (HCWs) [53]. Most of these studies were from low-income settings in Sub-Saharan Africa, and 5 of the 6 considered interventions in conflict or post-conflict environments.…”

Strengthening vaccination delivery system resilience in the context of protracted humanitarian crisis: a realist-informed systematic review

“…These included two that looked at macro-level financing -specifically the value or otherwise of development aid in promoting improved health outcomes, including for vaccination, and system-strengthening in Gavi supported countries (47,48); one study that considered private sector provider engagement in routine immunisation provision (49); and four that considered in one way or another improvements to local level incentives for vaccination delivery (50)(51)(52)(53). Of these four, three studies considered explicit incentivisation to facilities or health workers via pay for performance (P4P) (50)(51)(52); and one considered improvements to disbursement of programme funds to local level to promote vaccination delivery as a means of reducing the risk of delayed payment to HCWs (53). Most of these studies were from low-income settings in Sub-Saharan Africa, and 5 of the 6 considered interventions in conflict or post-conflict environments.…”

Mobile Money and the importance of timely, complete payments to frontline health campaign workers in the fight to eradicate polio: pilot experience from a World Health Organization digital payment platform in Africa

“…In a study conducted prior to 2004, researchers found that the success of Nigeria’s polio eradication initiative depended on timely, direct, and full payment of vaccination personnel [ 7 ]. Following the establishment of a Mobile Money payment system for frontline workers, challenges with making timely, direct, and full payments to workers were overcome.…”