New Incentives works in northern Nigeria, with operations in Katsina, Zamfara, and Jigawa States. These areas of operations are mostly rural, most of the caregivers we work with do not have mobile devices, and the clinics are very basic (often without power or plumbing). The lack of a constant power supply in these areas leads to reduced access to information and lower levels of awareness of precautionary measures for COVID-19. According to the World Health Organization (WHO), COVID-19 is disrupting life-saving immunization services around the world, putting millions of children at risk of diseases like diphtheria, measles, and pneumonia. In Nigeria, federal and state governments are taking proactive steps to curtail the spread of coronavirus throughout the country. The Government of Nigeria has been making significant efforts to contain the spread of COVID-19 in Nigeria, including significant economic measures. As of August 21, 2020, there are more than 50,000 COVID-19 cases reported (NCDC). As with many other countries, the actual number of COVID-19 cases can be challenging to track, and reporting might be incomplete. New Incentives has focused on carefully designing our COVID-19 response to be consistent with national guidelines, using technology for monitoring self-reported symptoms and adherence to instituted measures, and continuously evolving our response, taking into account the level of risk and disease transmission.
COVID 19 is disrupting life-saving immunization services around the world, putting millions of children—in rich and poor countries alike—at risk of diseases like diphtheria, measles, and polio. According to data collected by the World Health Organization, UNICEF, Gavi, and the Sabin Vaccine Institute, provision of routine immunization services is substantially hindered in at least 68 countries and is likely to affect approximately 80 million children under the age of one living in these countries (Source).
New Incentives is a nonprofit that implements cost-effective conditional cash transfer (CCT) programs, one of the most well-researched and successful methods in development aid, to increase demand for immunizations. Our goal is to increase the number of caregivers (typically the mother of the infant) who come to clinics to get their infants immunized. If we do this successfully (something that was evaluated in a Randomized Controlled Trial), we get more caregivers to come to the clinics during immunization sessions. These visits to the clinic and exposure to others from outside their own communities could, in theory, increase the spread of COVID-19. While there might be some risks associated with increased interpersonal contact during a clinic visit, these risks are far outweighed by the risks of not vaccinating children. Lower immunization rates in these communities could place infants at a greater risk of deadly vaccine-preventable diseases like measles. This risk assessment is shared by global experts and by local authorities, emphasizing that vaccinations are essential and should continue with risk mitigation plans in place. This is consistent with actions instituted by the Government of Nigeria.
According to benefit–risk analysis in the Lancet of health benefits versus excess risk of SARS-CoV-2 infection, “in the high-impact scenario, for every one excess COVID-19 death attributable to SARS-CoV-2 infections acquired during routine vaccination clinic visits, 84 (95% UI 14–267) deaths in children could be prevented by sustaining routine childhood immunisation in Africa” and “the deaths prevented by sustaining routine childhood immunisation in Africa outweigh the excess risk of COVID-19 deaths associated with vaccination clinic visits, especially for the vaccinated children.”
As COVID-19 started spreading in Nigeria, we aligned our COVID-19 Response with the guidelines provided by the National Primary Health Care Development Agency (NPHCDA): Preparedness and Response to Coronavirus Disease 2019 (COVID-19) at Primary Healthcare and Community Level. The guidelines advised that essential primary health care services like immunization should be prioritized, and our engagement with the State Primary Health Care Development Agencies/Boards (SPHCDA/Bs) in three states of operation has resulted in their provision of a written approval for us to continue our conditional cash transfer for routine immunization intervention during the COVID-19 period. In addition to working with the government to ensure alignment with state and national guidelines, we made substantial changes to our operating protocols in order to minimize risks. These measures included education, awareness, handwashing, physical distancing, and related monitoring to assess adherence to these efforts.
According to WHO, COVID-19 is disrupting life-saving immunization services around the world, putting millions of children at risk of diseases like diphtheria, measles, and pneumonia.
In order to preserve access to essential services without creating undue additional risks, we systematically identified risk vectors and designed ways to mitigate them.
Our goal is threefold:
Protect caregivers and clinic staff at clinics.
Protect our staff.
Protect the rural communities where our staff travel to verify vaccinations and disburse conditional cash transfers. In other words, we must minimize the risk that our staff becomes a vector in spreading the virus to smaller communities.
We designed our COVID-19 response in a manner that can integrate with our standard operational procedures. New Incentives’ Field Officers travel from their homes to clinics for Immunization Sessions or days when immunizations are offered at these clinics, usually occurring one to five times per week. Our measures are divided into three categories based on the occurrence of these Immunization Sessions:
Review of COVID-19 Cases and Decisions
Education Through Town Announcers
Field Officer Check-in, Mobile Application Screening and Reporting
Use of Face Masks and Hand Sanitizer
Education and Awareness During Health Talk and Disbursements
Physical Distancing at Clinics (including mats as visual cues)
Staff Hygiene While Disbursing Cash
Managerial Review of Monitoring
Field Managers use phone calls to screen each Field Officer for symptoms one day before the Immunization Session at the clinic, asking them about potential symptoms, listening to potential concerns, and asking about suspected or confirmed COVID-19 cases at or near the clinic.
New Incentives actively monitors COVID-19 cases in each State and Local Government Area (LGA) where we operate. If there are known cases of COVID-19 in a State and the government’s contact tracing team has not been able to identify and isolate all suspected and known cases, we assess whether to temporarily cease distribution of cash transfers at clinics in high-risk areas. If the assessment finds COVID-19 cases in an LGA and determines that the potential risk of providing cash transfers could be high, we pause operations at the clinic for at least 14 days until the individuals identified with COVID-19 are isolated to reduce the risk of an immunization session being the cause of the spread of COVID-19 in these communities. Cases of COVID-19 are monitored for each staff member’s residential location, and prompt action is taken to isolate potentially exposed staff members.
New Incentives engages community members who make announcements at settlements, also called “town announcers,” to raise awareness about the program and immunizations. Town announcers remind caregivers to return on time with their infants for immunizations. A simplified but standardized message in English and Hausa languages was prepared in a leaflet form and provided for town announcers to use in communicating information on COVID-19. As part of our ongoing awareness raising about immunizations and our program, we embed this message in the town announcers’ locally customized communications.
Before traveling to a community or clinic for an immunization session, Field Officers fill out a brief form covering various questions about potential symptoms, known or suspected cases in their locality, their understanding of guidelines related to program COVID-19 precautionary measures, and possible interactions with others who might have symptoms. These questions reinforce hygienic measures such as washing hands, wearing a mask, and using hand sanitizer when handwashing is not possible. This is done through an internal mobile application called the myDay App. This app asks screening questions for COVID-19 core symptoms and prevents the Field Officers from proceeding to the clinics if a symptom is identified from the responses. Field Officers can choose not to travel to clinics during the COVID-19 period without facing negative employment consequences, a policy enacted to encourage honest reporting.
The organization provides masks and hand sanitizers to all employees. In line with government guidelines in Nigeria, Field Officers wear masks during transit to and from the clinics and during immunization sessions. Field Officers are required to use their hand sanitizers after cash disbursements in addition to washing their hands before and after leaving the clinic. A custom distribution app tracks the distribution and stock level of these items so that Managers and Logistics Officers can replenish depleted items.
Since a majority of the clinics we operate at lack wash basins with steady water, we purchased water dispenser buckets, water collecting and filling buckets, and liquid handwashing soap to provide a handwashing station in all clinics. Since water dispenser buckets with pistons are not readily available, we had to get these attached through some creative handiwork and were able to distribute them throughout our partner clinics. Switching the piston of the bucket on and off and contactless dropping of liquid soap on the hands of visitors to the clinic are secondary responsibilities of the engaged community member. Active guidance is provided by the community member to reinforce washing hands for 30 seconds, something many caregivers practice for the first time.
In the rural areas where we work, many caregivers coming to the clinics had not heard about COVID-19, particularly when we first started implementing precautionary measures. We were able to team up with clinic nurses to create awareness around COVID-19 and precautionary measures that should be taken to reduce risks. These measures are covered during a health talk at the start of each immunization session and are reinforced by Field Officers during each cash transfer disbursement.
Maintaining physical distancing at clinics is the most significant challenge that we face. The average volume of caregivers coming to clinics we operate at is around 30 and can be higher than 100. The caregivers are guided to observe physical distancing, but clinics usually do not have adequate seating arrangements, leading to caregivers needing to stand or sit on the bare floor (which does not encourage adherence to physical distancing).
We were able to address the distanced seating arrangements by engaging select community members responsible for maintaining social distancing and distributing mats at clinics with mandates of a maximum number of adults allowed per mat. We monitor adherence to these measures through photos clicked every two hours (called “Bihourly Monitoring”). Bihourly Monitoring yields insights we use to make decisions for challenging clinics. There have been scenarios where we need more space to ensure caregivers are comfortable and not put at risk while waiting for disbursements with their infants. Clinic staff and our team have implemented innovative ideas like using nearby empty public government facilities (temporarily closed due to COVID-19) to give caregivers adequate space to wait. These are some of the applied measures to ensure physical distancing:
Provision of Mats for Clinics: We distributed mats (called “Tabarmar Leda”) to clinics, mandating at most four adults to sit on edges of the mats at a time. These mats prevent sitting on bare floors and serve as visual cues, which is more effective than asking caregivers to sit at a distance of two arms length apart. Various versions of this were attempted.
Engagement of Community Members: At the majority of clinics, we now engage community members, usually one to two per clinic, to be responsible for ensuring that physical distancing is adhered to while clinic staff is vaccinating infants and our team is disbursing cash. They are given a small stipend for this sole responsibility or as part of their other responsibilities like identifying outside catchment beneficiary fraud and defaulter tracking. Community members can be Volunteer Focal Persons (VFPs), Traditional Birth Attendants (TBAs), influential members in the community, or sometimes program enthusiasts willing to volunteer. While finding community members to volunteer was not challenging, not everybody was successful with this responsibility. The process began with some false starts before we identified the best community members who could assist us with these objectives.
Bihourly Monitoring: A majority of the clinics where we operate do not have steady power or internet so identifying a low-cost method to monitor adherence to COVID-19 safety protocols was particularly challenging. To achieve the monitoring goal, our Field Officers take a break at least every two hours from the cash transfer disbursements to submit answers to adherence monitoring questions and to capture photographs of all caregivers waiting, both inside the clinic and outside the clinic waiting areas. These are low resolution, making storage more accessible and reducing the risks associated with handling photos while still enabling managers to get a relatively clear picture of physical distancing adherence at the clinics. The photos turned out to be a game-changer, allowing managers to assess the areas with issues and put forth solutions quickly.
Mats serve as visual queues, which turned out to be more effective than continually asking caregivers to sit at a distance.
Two key measures reinforce hygiene at clinics:
Socially Distanced Disbursements: We modified our protocols to ensure that our Field Officers can maintain a one- to two-meter distance from each caregiver while disbursing cash. Cash is placed on the table for the caregiver to pick up to avoid breaking the physical distancing rule.
Hand Sanitizers and Masks: We distributed hand sanitizers and masks to all Field Officers. Field Officers update their stock each week so that their managers can promptly replenish their stock when a Field Officer is running low on these supplies.
At the end of each immunization session, the Field Manager checks in with the Field Officer to inquire whether they encountered anyone with COVID-19 or heard about any cases of COVID-19 at the clinic or the surrounding villages or were exposed to others who might have related symptoms. This is in addition to the usual review of the day’s immunization session.
Field Managers review the various photos submitted during immunization sessions for a documented assessment. They evaluate the photos for critical areas of concern: adherence to physical distancing, number of caregivers present in the images (to ensure pictures are representative of the number of caregivers that attended the specific immunization session), and the presence and usage of the handwashing station. These inputs form part of a more extensive assessment for each clinic on COVID-19 training, adequacy of related supplies, adherence to physical distancing, adequacy of bihourly monitoring, and representative nature of submitted photos, based on a defined scoring criterion: Pass or Fail; if Fail, level of severity (Low, Medium, High). Where the assessed risk is too high, a manager implements a solution, or sometimes a recommendation to pause cash transfer disbursement is made and ratified during review meetings until the manager and clinic staff choose a path. We had to do this several times, and we found that it has led to collective action such as village leaders volunteering to assist with enforcing physical distancing.
We modified our protocols to ensure that our Field Officers can maintain a one- to two-meter distance from each caregiver while disbursing cash. Cash is placed on the table for the caregiver to pick up to avoid breaking the physical distancing rule.
The precautionary measures have the support of the State Primary Health Care Development Agencies of Jigawa, Katsina, and Zamfara States. The representatives of these three states reviewed this article, and we appreciate their partnership and support in helping increase the immunization coverage in northern Nigeria.