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Tracking and Reaching Zero-Dose Children in Nigeria

June 10, 2024

New Incentives is dedicated to the global goal of dramatically reducing the number of zero-dose children—defined as children who haven’t received a single dose of diphtheria-, tetanus-, and pertussis-containing vaccines. Zero-dose children are the most vulnerable, accounting for nearly half of all vaccine-preventable deaths.

Our efforts to reach zero-dose children include gathering granular data on where these children live, conducting targeted outreach to their families through awareness sessions and mobile vaccination units, boosting demand for vaccination through cash incentives, tracking progress over time, and sharing our findings with relevant government stakeholders and partners. 

Closing the Vaccine Equity Gap: The Global Challenge of Reaching Zero-Dose Children

At least 14.3 million children do not receive basic, routine vaccines each year. A global effort is underway, led by Gavi, the Vaccine Alliance, to dramatically reduce the number of unvaccinated children. Two-thirds of these zero-dose children lived in just five countries in 2019: Nigeria, India, the Democratic Republic of the Congo, Pakistan, and Ethiopia.

Nigeria, the most populous country in Africa, has 2.3 million children who have not been immunized, the second-highest number in the world. In Nigeria, immunization coverage is lowest in the north. Finding effective ways to identify and reach these children is crucial to achieving full and equitable vaccination coverage.

Identifying Where Zero-Dose Children Live

On a sunny day in March, Ismail Dahirua, a New Incentives field officer, and a clinic staff member arrived in the village of Maji Dadi, in the northeastern Nigerian state of Gombe, to get a read on the vaccination status of children in the village. 

The short surveys, or  “rapid checks,” they came to conduct are one of the ways New Incentives gets real-time data on the vaccination status of children in the areas where we work. Data from these checks signals to our teams where and when to focus our activities: in villages with high numbers of zero-dose children, we send teams to raise awareness about the importance of vaccines and the New Incentives program. In villages with a high number of children who have missed out on vaccinations, we work with local clinic staff to carry out mobile vaccination sessions

We use satellite data to identify population clusters and plan activities, ensuring our outreach is data-driven and no communities are left behind because they are far from a clinic, only reachable by difficult terrain, or of a different ethnic group.

The checks are simple, but they are done carefully, abiding by cultural customs and with support from village leaders and community members. When Ismail and the clinic staff arrived in the village that day, they first went to the home of the village leader, where they informed him they would be carrying out a rapid check and asked if he could provide a guide to accompany them. 

We use satellite data to identify population clusters and plan activities, ensuring our outreach is data-driven and no communities are left behind.

The village leader was helpful and assigned a trusted member of the community named Muhammad Isa to accompany them. Muhammad knew everyone in the village, including which families had young children.

Together the three of them stopped at compounds of round mud huts surrounded by grass fences and baobab trees. They greeted the adults and gently asked them if they would be willing to participate in a quick survey.

“Zan iya ganin katunan rigakafin yaranku?” the clinic staff member asked a mother in Hausa, requesting that she show them her child’s vaccination cards. She went into her home and produced a worn card—her child’s vaccinations were up-to-date. However, many families in the village were not able to show that their children were vaccinated.

GPS data allows for verification that protocol was followed and no houses were skipped during the survey.

On that day, the team visited 25 households. For 12 of the households, a parent was home and consented to the brief interview. Six of them informed Ismail that their children had been vaccinated and brought out the child health cards as proof. However, the other six households they spoke to let him know that their children weren’t vaccinated. Upon probing further, the field officer learned that some have refused vaccination on the grounds of religious beliefs, while other households shared no specific reasons for not bringing their child for immunization. 

With permission from caregivers, field officers take photos of child health cards to verify vaccination status.

Outside each home, Ismail took a photo with GPS coordinates that he immediately added to his daily work report. Later, once he’s back home with a better internet connection, he will sync the images to the New Incentives server. The high number of unvaccinated children and those with an unknown status means that the village will be flagged in his daily report as needing an awareness campaign or mobile vaccination visit and the information will be reviewed by a manager. Subsequently, a work plan will be created for a visit to this location for the activity.

The field officer captures the entrance of each house and GPS coordinates as he conducts the surveys; this allows managers to confirm the house was visited and the correct pattern was followed.

Between May 2023 and April 2024, New Incentives staff coordinated over 24,000 awareness sessions and participated in more than 106,000 mobile vaccination sessions. In mid-April, Ismail returned to the same village with a mobile vaccination unit for a targeted outreach. During that session, they enrolled 15 new infants (most of whom were zero-dose infants) in New Incentives’ program. 

New Incentives staff coordinated over 24,000 awareness sessions and participated in more than 106,000 mobile vaccination sessions.

Boosting Demand for Vaccination with Incentives

In addition to the efforts described above, a key way we reach zero-dose children is through the centerpiece of our program: offering cash incentives for vaccination. Our program is based on global evidence of the effectiveness of small cash incentives in boosting vaccination rates, as well as an RCT of our program in Nigeria. The small transfers—each less than US$1 and offered at six routine immunization visits—are proven to increase the number of fully vaccinated children by 108%. 

Tracking Progress on Reaching Zero-Dose Children

The proportion of zero-dose children has reduced substantially in the areas where we operate, based on data from our coverage surveys. These surveys are conducted six months before we expand to a new geographic area and every six months after the program has been rolled out. New Incentives does not take full credit for this change, given that other efforts are underway to reach these children—our data cannot demonstrate that our program solely caused the impact. However, this data is a key part of our monitoring strategy and, in combination with the findings from our RCT, helps us estimate our program impact. We believe the significant reduction in zero-dose children can largely be credited to the high-quality implementation of our evidence-based program, enabled by close collaboration with our state and local partners. 

Sharing Our Data with States and Other Stakeholders

New Incentives shares data with state partners, Gavi, and other stakeholders to support broader efforts to reach zero-dose children.

In monthly and quarterly reports, we break down key indicators such as enrollments, immunization rates, estimated uptake, documented stockouts, and activities by each area where we operate. You can see our latest report here.

We also share the findings of our coverage surveys via virtual and in-person meetings with key state officials. We also communicate daily with cold chain officers at every level of the vaccine supply chain in order to share data and avoid stockouts.

Big Impact, Collective Effort

Our efforts to reach zero-dose children through rapid checks and by leveraging satellite population data are relatively new and evolving, but we are encouraged by the substantial reductions in zero-dose children we are seeing in the areas where we operate. It shows that our efforts, and those of others in the sector, are working. Along with the many actors involved in addressing low vaccination rates, we are confident that, at least in Nigeria, we will achieve or even surpass Gavi’s global goal of cutting the number of zero-dose children in half by 2030. 

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