New evidence: Conditional Cash Transfers Increase Immunization Coverage in North West Nigeria
A clustered randomized control trial shows that the New Incentives — All Babies Are Equal Initiative’s conditional cash transfer program increased BCG, Penta vaccine, Measles vaccine, and full routine immunization coverage in North Western Nigerian communities.
By Alison Connor, Sophia Schneidewind, Zack Devlin-Foltz
Immunizations are among the most cost-effective ways to reduce child mortality and morbidity in low and middle-income countries. Still, families living in Nigeria face significant barriers to accessing immunizations, and 40% of deaths of Nigerian children under the age of five years are attributed to vaccine-preventable diseases. Health policy-makers and NGOs have a difficult task at hand: How can they best support families to immunize their children?
New results from a clustered randomized control trial conducted by IDinsight shows that modest cash incentives given to mothers or caregivers who vaccinate their children, coupled with awareness creation and vaccine stock management, can meaningfully increase coverage of routine immunizations.
The non-profit, New Incentives — All Babies Are Equal Initiative (NI-ABAE) has implemented a program in Katsina, Zamfara, and Jigawa States in North West Nigeria that provides small cash incentives to caregivers whose infants are immunized at participating health clinics in addition to raising community awareness on the benefits of vaccines. The logistics of providing cash transfers in rural areas, like the three states studied, can be difficult. Few community members have mobile phones, which means mobile payments aren’t the best option. To manage the challenges of distributing cash, the program trains local staff, has detailed protocols and tracking systems, and conducts ongoing audits and supportive supervision.
Generating data to inform decision-making
To estimate the impact of NI-ABAE’s Conditional Cash Transfers for Routine Immunizations Program on childhood immunization coverage, IDinsight worked closely with our Nigeria-based partner, Hanovia Limited, to design and conduct an RCT. The evaluation was funded by Open Philanthropy at the recommendation of GiveWell, a nonprofit dedicated to finding outstanding giving opportunities. GiveWell recommended funding the study to better understand the impact of New Incentives, which it considered a potential future GiveWell top charity.
Additionally, IDinsight engaged state- and national-level policymakers and public health experts during a stakeholder meeting prior to the design of the endline survey to better understand the research questions that were top of mind for decision-makers beyond NI-ABAE. Our endline survey included their additional questions that focused on the program’s impact on caregiver attitudes toward and knowledge about vaccinations as well as on vaccine stock at clinics. While the endline occurred too early to measure sustainability and long-term effects on health systems, economic empowerment, and health decision-making, future research can help answer these critical questions for policy-makers.
To ensure the results were most relevant for Nigerian policy-makers and researchers, IDinsight also engaged six academic and technical experts to provide feedback on the rigor of the study as well as the interpretation of the results. Their input and critical questions strengthened the relevance of our findings to its various audiences.
IDinsight and Hanovia collaborated with the Katsina State Primary Health Care Development Agency, the Zamfara State Primary Health Care Board, and the Jigawa Primary Health Care Development Agency to disseminate the results to technical stakeholders and traditional and religious leaders across these three states. These meetings provided an opportunity to share the findings with those who had supported the study since the baseline survey in 2017. Without their collaboration, the research would not have been possible.
Due to COVID-19 restrictions, we shared English and Hausa versions of our results presentation ahead of live, remote meetings to answer questions, receive feedback, and discuss the findings. The reception was overwhelmingly positive.
“I would like to congratulate the team for successfully completing a cluster RCT,” said Dr. Nafisa Sani Nass, the Director of Primary Health Care at the Katsina State Primary Health Care Development Agency. “The State Primary Health Care Development Agency now has an evidence-based strategy that works for consideration in further improving its immunization coverage aimed at preventing vaccine preventable diseases.”
“The NI-ABAE for RI program is a valid intervention,” said Dr. Kabir Ibrahim, the Executive Secretary of the Jigawa State Primary Health Care Development Agency. “We, the Jigawa State Primary Health Care Development Agency, are part and parcel of this program. The results from the evaluation have been fully studied and they are representative of what we have done in the field during the last few years. This is good work.”
In collaboration with the Ministry of Budget and National Planning (MBNP) and National Social Safety-Nets Coordinating Office (NASSCO), IDinsight and Hanovia disseminated the results to a group of over 60 national-level stakeholders. Other national-level dissemination events are planned for a future date for stakeholders who could not be invited, or who could not attend the recently held national dissemination meeting. The national dissemination meeting was declared open on behalf of the federal government of Nigeria by the Minister of State for Budget and National Planning represented by the Director of International Cooperation. In their remarks, it was stated:
“On our part, I am pleased to inform you that the Federal Government remains committed to the sustainable implementation of the recommendations of the impact evaluation findings as contained in the research report. Let me reiterate that the Government of Nigeria is committed to the aspiration to lift 100 million Nigerians out of poverty, hence interventions that bring about the improvement in the health of Nigerians as well as cash transfers to stimulate economic growth are welcomed.”
The engagement and feedback from all dissemination efforts has been invaluable in ensuring the results are decision-relevant, the ultimate aim of all IDinsight evaluations. (Watch the results video here.)
Summary of Findings
The RCT results are compelling: children in NI-ABAE’s program communities were 27 percentage points more likely to be fully immunized (received BCG vaccine, three doses of Pentavalent vaccine, and Measles vaccine) than children in control communities (Fig 1). It also had a large, consistent, positive impact on the coverage of individual vaccines that it incentivizes. NI-ABAE’s program resulted in a 16 percentage point increase in BCG vaccine coverage, a 21 percentage point increase in coverage of the first dose of pentavalent vaccine, and a 14 percentage point increase in Measles vaccine coverage. These findings ultimately mean that more children are protected from vaccine-preventable diseases and the threat they pose to life.
Because immunizations for children under five are maximally protective if given on a strict timeline, the program also aims to compel caregivers to vaccinate their children on schedule. The RCT found that children who received the Measles vaccine in NI-ABAE areas were 33 percentage points more likely to receive it within one month of the recommended age.
The program also had positive effects on other immunization and health outcomes, including coverage for vaccinations not directly incentivized by the program, but that are part of the Nigerian RI schedule and first-time visits to health clinics. Caregivers in the areas where the program operates also had better knowledge of and more favorable attitudes toward immunization as compared to their counterparts not receiving the program. These are promising signs that the NI-ABAE Program can help increase demand for routine immunization in the long term, though future research will be needed to confirm this.
Further, the RCT findings suggest that the program also improves vaccine supply. NI-ABAE staff check the quality and supply of vaccine stock at program clinics a day prior and on RI days. If stock is low, they encourage clinic staff to procure more vaccines. As a result, the percentage of program facilities reporting no vaccine stockouts during the 12 months preceding the endline survey was 18 percentage points higher compared to the percentage of control facilities.
Finally, the research indicated that the control group also saw an increase in immunization coverage of about 20 percentage points depending on the vaccine. This is encouraging given the efforts by the Government of Nigeria and other partners to improve immunization coverage. That the NI-ABAE program led to considerable additional improvement in vaccination coverage means it may be an important addition to the broader immunization strategy in Nigeria.
This RCT found that NI-ABAE’s program substantially increased coverage of routine childhood immunizations in low coverage areas. These findings suggest that modest conditional cash transfers could have a profound impact on ensuring that children in North West Nigeria access life-saving immunizations and could be an important complement to other ongoing programs.
 Program and control catchment areas all met NI-ABAE’s operational criteria — they were all places the program could have operated. IDinsight selected half of these catchment areas at random and NI-ABAE actually operated in this randomly selected half. Communities were spaced far enough apart that it was difficult for control caregivers to access the program and study results found no evidence of such “contamination.”
 We did not find clear evidence of an effect on timeliness of BCG vaccination. The NI-ABAE program improved timeliness within 2 weeks of the first dose of Penta vaccine, though this impact was no longer evident within 1 month of the recommended age (at 6 weeks).
We would like to acknowledge and thank everyone who made this RCT possible: Our co-PI, Segun Oguntoyinbo. Our many IDinsight colleagues who contributed to this work, especially Sebastian Łucek, Niklas Heusch, Steven Brownstone, Maureen Stickel, Daniel Stein, Mallika Sobti, Deng-Tung Wang, Radhika Lokur, Magdalena Anchondo, Sarah Carson, Nyambe Muyunda, Martin Gould, Michael Henry, Jacqueline Mathenge, and Felicia Belostecinic. Our research partner, Hanovia Limited: Kola Durojaye, Sheni Adejumo, Hashim Hassanu, Dr. Seye Ajayi, Dr. Usaku Ogunbiyi, Dr. Musa Yakubu, Sunday Orinya, Folakemi Omotayo, Garba Abdullahi, Emeka Ochije, Arshad Yakasai, and the rest of Hanovia Limited’s team; IDinsight’s field managers: Mariam Bako, Elizabeth Bello, Sophie Emmanuel, Clara Ibrahim, Saraya Dauda Loya, Charity Usman, and Sandra Wilson.
Thank you to our implementing partners: Svetha Janumpalli, Pratyush Agarwal, Patrick Stadler, Obinna Ebirim, Nura Muhammad, Mubarak Bawa, Kennedy Theman, Idoko Paul, Dhanasiddharth Selvam, Rahul Kulkarni, and the rest of the New Incentives — All Babies Are Equal Initiative team; Anna Heard; Nigeria’s National Health Research Ethics Committee, Zamfara State Health Research Ethics Committee, Katsina State Health Research Ethics Committee, and Jigawa State Primary Health Care Development Agency who granted us ethical approval to conduct this study; the Federal Ministry of Health, the Ministry of Budget and National Planning and the National Social Safety-Nets Coordinating Office, the Katsina State Primary Health Care Agency, Jigawa State Primary Health Care Development Agency, and Zamfara State Primary Health Care Board; Our academic and technical reviewers: Prof. Beckie Tagbo, Prof. Auwal Umar Gajida, Prof. Aisha Abubakar, Pharm Adamu Gachi, Dr. Ahmad Abdulwahab, and Prof. Musa Abdullahi; All of the caregivers and clinic staff in Katsina, Zamfara, and Jigawa States who agreed to participate in this RCT.
This RCT in Katsina, Jigawa, and Zamfara States was preceded by a small pilot study conducted in Anambra, Akwa Ibom, and Nasarawa States primarily to help our implementing partner determine the optimal incentive amount for the Measles vaccine. This pilot study is different from the study presented here and is the subject of an inquiry by the National Health Research Ethics Committee, Nigeria (NHREC) related to timing of the ethical review and omission of local authors in a paper on the pilot study that was published in the PLOS ONE journal. IDinsight has provided responses to NHREC’s questions and awaits a resolution of that matter. IDinsight has retracted the related publication and has updated its internal research ethics policies. The RCT reported in this post is separate: it took place in Jigawa, Katsina, and Zamfara States and had the necessary approvals and permissions. More details are here.