From Insight to Action: How Our Pilot Plans to Strengthen Routine Immunization in Kogi State, Nigeria

Hello again from Notify Health! Over the last few months, we’ve taken significant steps forward, including conducting two needs assessments in the Nigerian states of Kogi and Ogun. The insights are fascinating and will prove vital to designing a pilot that is grounded in evidence whilst being tailored to the local context.

Summary:

• The needs assessment provided key insights: most caregivers prefer automatic voice calls, people receive a high number of messages already (mostly from mobile companies), and immunization register quality varies greatly between facilities

• The pilot will launch in Kogi state in the coming days. We expect to enroll around 3500 children, leading to an additional 70-280 children immunized with the penta-3 vaccine

• We have a mass messaging system that is ready to send hundreds of SMS and automatic voice calls out every day

• You can now donate to Notify Health with tax deductibility available for many countries

Needs Assessments

When designing a program, there really is no substitute for interfacing directly with your beneficiaries. Through July and August, we conducted two needs assessments in Kogi and Ogun states that did just that. In collaboration with our local partners, we visited health facilities, surveyed caregivers in their homes, and followed up with some over the phone. Overall we spoke to around 200 beneficiaries (health workers and caregivers combined). We also ran through a prototype of all our program processes to improve them before the Pilot.

Here are some key findings with direct implications for program design:

• Automated voice calls are preferred: In Kogi, a notable 58% of caregivers preferred automatic voice calls alone, 17% preferred SMS alone, and 25% liked both options. This, combined with the fact that only around 37% of mothers in Kogi were able to read a message that we presented to them, means we may want to send voice calls to a wider cohort of caregivers than we initially thought.

• People already get quite a few messages: on average, people receive 5 - 10 SMS and 5 phone calls per day. Many of the SMS messages are advertisements or freebies from phone companies… “ENJOY ONE HOUR OF FREE BROWSING!”… They may send you a dozen messages every week. This means unless our messages stick out somehow, they are likely to be lost in the abyss of free data bundles and social media airtime. We hypothesize that our voice calls and message design with trust-building components can stand out.

• Baseline paper record quality varies widely: The percentage of children with recorded caregiver phone numbers ranged from 90% in some clinics to 0% in others. The issue seems partly due to a lack of habit in recording phone numbers, rather than caregivers not owning phones. While the low rate of data collection poses a challenge, it is a challenge that could be addressed: by encouraging health workers to recognize the importance of recording phone numbers and building the habit of asking for them, we could significantly improve phone number collection in these clinics. We will test this in our pilot.

Planning for the pilot

We are pleased to announce our plans to launch a pilot in Kogi State, Nigeria! When you read this, we are just days away from enrolling the first caregivers and children  into our program. Kogi State provides very promising conditions for our program to be highly impactful and cost-effective. At scale, we think we can reach more than 100,000 parents of newborn children in Kogi every year driven by high phone ownership, and health facility attendance at or shortly after birth. Despite strong birth vaccine coverage, drop-out rates in the first 14 weeks of life are in the top four of all 36+1 states in Nigeria. 55% of caregivers say this is because of a lack of knowledge or forgetting about the schedule (MICS 2021, p 200/201). These are reasons our program can address well.

Notify Health Co-founder Daniel convened with stakeholders from the Kogi State Primary Healthcare Development Agency recently to discuss the results of the needs assessment and to agree on the pilot scope and message design. While the results from Ogun were equally promising in terms of the potential impact of our program, we chose Kogi to launch this year due to the strong support we have received from the Kogi Primary Healthcare Development Agency, as well as having confidence in our partner Renaissance Care and Empowerment Foundation (RECEF) to deliver a high-quality, cost-effective pilot. We remain excited about the opportunity for impact in Ogun and hope to launch a pilot there early next year if our program pilot in Kogi is successful.

In collaboration with the Kogi State Primary Health Care Development Agency, we have selected 45 health clinics to include in our pilot. Over the next three months, our partner’s staff will visit these clinics to take photos of their immunization registers, which we will then digitize to enroll children and their caregivers into the program. We expect to enroll approximately 3500 children, or roughly 8.5% of the children born in Kogi over that period. A very rough estimation is that already in the pilot, through sending a total of around 21,000 reminders we could protect an additional 70-280 children might have otherwise missed it with the third Penta vaccine (That protects against Diphtheria, Tetanus, Pertussis, Hepatitis B, and Haemophilus Influenza). Of course this number is preliminary, and would only hold true if our program impact is in line with some of the prior academic studies, which is a key uncertainty we want to investigate.

We have three questions we most want to answer in the pilot:

• Is our enrolment strategy scalable and potentially cost effective?

• Are caregivers receiving, reading, and understanding our messages as intended?

• Do we think that we are improving attendance at immunizations, even if we cannot be confident in the exact amount?

If the answer to all three of these questions is yes, then we can start to move on to getting the program to as many children as possible. If the answer is no, then perhaps we need to go back to the drawing board, and reconsider some of our key assumptions about how the program should be run.

Mass messaging system

The last months we have also built the first version of our mass messaging system. Capabilities we need for the pilot like sending SMS or pre-recorded calls to hundreds of caregivers at once are in place and tested thanks to the help of our generous alpha testers in Nigeria, and through sending general health information to around 400 caregivers.

We have programmed in the routine childhood immunisation schedule of Nigeria to send reminders at the right time, and have recorded voice reminders in five local languages. The right language for every caregiver is automatically picked based on information about communities around a specific health facility. Individual SMS are tailored to not only remind caregivers that it is time for their child’s immunisations, but also to tell them what day of the week their specific clinic providers immunisation. With the help of some generous volunteers, we are also working on further automating the entire enrolment process to improve cost effectiveness.

The future potential of the system is exciting too. We have already technically tested WhatsApp as a further reminder channel that could proof impactful and data-rich, and many more steps could be automated. Stay tuned for more!

Effective Altruism Nigeria Summit

In early September, Daniel had the opportunity to attend the inaugural Effective Altruism Nigeria Summit in Abuja. It was a great chance to connect with the growing community of people in Nigeria that are driven by impact, evidence and cost-effectiveness. We met with many advisors helping us to navigate the Nigerian health system and other local questions, people interested in supporting Notify Health in the future, and other organisations that we can learn from and share resources with.

We look forward to continue engaging to overcome some of the challenges Nigeria faces on the path to its full potential.

Call to action

If you share Notify Health’s vision of a future where every child can thrive, free from preventable diseases, there are several ways you can contribute:

• Donate: You can now support our work through donations. Tax-deductible options are available depending on your country.

• Volunteer: We’d love to hear from you! Please fill out our volunteer interest form. We’re especially eager to connect with individuals who bring a strong background in statistics, coding, finance management, or research.

• Follow & share: Stay connected by subscribing to our newsletter and following us on Linkedin. We’d also appreciate if you could forward this email to anyone who might be interested in our work.

• Feedback & Guidance: Your feedback is valuable to us. If you’d like to share ideas, or if you have relevant expertise and believe your insights could contribute to our mission, please reach out to us at info@notifyhealth.org

Lastly, we’d like to extend our heartfelt thanks to our generous funders, our partners RECEF and HACEY Health Initiative, the team at Charity Entrepreneurship, our current and past volunteers, and all the experts and mentors who have supported us along the way.