Investigating The Enablers and Constraints to Equitable Access to COVID 19 Vaccine in Nigeria: A Diagnosis of Supply Mechanisms and Stakeholder Engagement

Effective vaccine distribution is crucial for ensuring timely and equitable access, especially for vulnerable populations. This study employed a cross-sectional qualitative approach, utilizing Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs) with purposively selected stakeholders, including representatives from government ministries, development partners, and other key actors in the vaccine ecosystem. Findings show that Nigeria’s vaccine supply chain operates at five levels, from the National Strategic Cold Store (NSCS) in Abuja to service delivery points (SDPs). Vaccines are distributed through six Zonal Cold Stores (ZCS), 36+1 State Cold Stores (SCS), satellite stores, and 774 Local Government Area Cold Stores (LGACS). The study identifies four main categories of challenges in vaccine distribution: individual, societal/cultural, environmental, and systemic. Key stakeholders in the vaccine distribution process include national, state, and local governments, development partners (WHO, UNICEF, GAVI, AFENET), the private sector (vaccine manufacturers and logistics firms), health facilities, and civil society organizations. To improve equitable vaccine access, recommendations include addressing vaccine availability (via local production), optimizing logistics, improving social infrastructure (transportation, electricity), and strengthening coordination and partnerships.

The coronavirus disease (COVID-19) is one of the biggest public health threats in recent times. It is associated with enormous health, economic and social consequences as well as public health security globally (Kimberly Chriscaden, 2020). The World Health Organization (WHO) officially declared the pandemic a public health emergency of international concern by the end of January 2020 (Guo et al., 2020). The pandemic had enormous socio-economic impacts both globally and within countries and communities. For instance, the COVID-19 lockdown periods were associated with a 34.1%

The study deployed a cross-sectional qualitative method including Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs). The KIIs were conducted with purposively selected stakeholders ranging from representatives of the relevant government ministries, departments and agencies, development partners within the infectious disease and vaccines ecosystem, CSOs, the academia and research institutions as well as selected diagnostic laboratories. On the other hand, FGDs were conducted on consumer groups representing male groups, female groups and community gatekeepers.

Population of Study

The study population involved different stakeholders within the COVID-19 vaccination value chain – from the national through the states and Local Government Areas (LGAs) to the last mile: relevant government Ministries, Departments and Agencies (MDAs) including National Centre for Disease Control (NCDC), National Primary Health Care Development Agency (NPHCDA), development partners (World Health Organization (WHO), Centre for Disease Control and Prevention (CDC), and community of practice (Nigeria Health Economics Association (NIHEA), selected COVID-19 diagnostic centres and health facilities, as well as consumers.

Sampling and Sampling Technique

The sampling for the qualitative interviews was purposive and took into consideration the representativeness of all the key stakeholders involved in the distribution and administration of COVID-19 vaccines at national and subnational levels in Nigeria. A snowball approach was used to identify more respondents until data saturation started emanating and same responses started coming out from subsequent respondents.

 Table 1: Sampled Respondents

The Interview Protocols were developed to guide the conduct of the key informant interviews and focus group sessions. They detailed the range of issues to be covered and how the discussions were to be conducted to elicit appropriate responses that would enable robust reflections and understanding of the research questions.

5 research Assistants (RAs) who collected the data, were recruited and trained on the goal, objectives and methodological requirements of the research. Two of the RAs are females (one PHD and one MSC holders) and 3 males (All graduate assistants with first class in different academic disciplines). A participatory, adult-centered training approach was used to deliver the training which included a review of the key approaches, data collection tools and reporting (background to the study, the study objectives, the study methodology, study tools, ethics, use of field manual, field procedure plans, and interviewing techniques). The training provided an opportunity for the research assistants to adequately understand and fulfil their respective roles and responsibilities confidently. They also familiarized themselves with the standard procedures for the study including the ethical dimensions.

As part of the coordination mechanism for the study, relevant stakeholders within the Nigerian vaccine supply chain ecosystem were identified, mapped and primed for engagement in the study (KII and FGD). However, a significant proportion (10/31 or 32%) of the prospective respondents (Two from National Agency for Food and Drugs Administration and Control, One from NCDC, one from CDC, One CSO (Vaccine Network), Two from FMOH, two researchers and one from UNICEF) declined to participate in the interviews for various reasons, or no reason at all.

KII and FGDs: The trained RAs worked in pairs, and used the developed project-specific KII and FGD question guides to conduct the sessions. Each KII and FGD session was audio recorded; the information was later transcribed into English. Twenty-one interviews were conducted, including five Focus Group Discussions (FGDs) and 16 Key Informant Interviews (KIIs). The FGDs consisted of three female groups and two male groups, as shown in Table 1. The data was cleaned and checked for consistency and accuracy and imported into a data analysis-enabled format (Codebook).  A thematic analysis of data was done to reflect the study objectives. The data analysis focused on specific variables of programmatic interest in line with the analysis plan.

Ethical Clearance

The study did not involve invasive procedures or the collection of sensitive personal information about the respondents. However, an ethical clearance (FHREC/2024/01/152/27-06-24) certificate for the study was obtained from the ethical review board of the Federal Capital Territory Health Department. Informed consent was obtained from each respondent or group before interviews by first providing detailed information about the study before asking for consent.

Respondents’ Demographics

Overall, 66% (21 out of the 32) interviews were conducted giving a total of 21 interviews across the KII respondent groups which comprised 19% males and 81 %  females. A greater proportion of the interviews (76%) were KIIs while 24% were FGDs with end users of the COVID-19 vaccines, as shown in Table 3. All the KII participants were educated up to tertiary levels and 74% of the FGD participants had only secondary school education, as shown in Tab 3.

Existing Mechanism of COVID-19 Distributions and Delivery

All the KII respondents reported similar steps and flow of COVID-19 vaccine distribution and delivery mechanisms in Nigeria. The country’s vaccine supply chain management system is operated at five levels – from the national level down to the Service Delivery Points (SDPs), as shown in figure 1. It was reported that there exists an operational mechanism for vaccine distribution and delivery including forecasting, procurement of the vaccines, safety testing by NAFDAC and other agencies, storage, distribution, delivery and service provision. Respondents stated that vaccines from the manufacturers including COVID-19 vaccines from the airport are stored at the National Strategic Cold Store (NSCS) in Abuja while the National Dry Store is situated in Lagos.

Vaccines and devices are transported from the national level to the last mile through the six Zonal Cold Stores (ZCS), 36+1 State Cold Stores (SCS) plus some additional satellite stores in several states and across the 774 Local Government Areas Cold Stores (LGACS). While vaccine stocks flow from the national level down to the last mile at the health facilities and other SDPs, Routine Immunization (RI) data and vaccine logistics management data flow from the last mile to the national level traversing several data aggregation points. Poor stock data visibility and weak vaccine accountability were identified as major challenges to the management of vaccine logistics and supplies in Nigeria, especially at the lower levels of the supply chain. Respondents reported that the COVID-19 vaccines have been integrated into the existing routine immunization system of the country.

Vaccines including the COVID-19 vaccine distribution mechanism in Nigeria involve a structured pathway from national to local levels involving Forecasting, Procurement and Supply. Vaccines are initially received at the national airports where national cold storage facilities are located. After passing safety tests by regulatory bodies like NAFDAC, they are stored under appropriate conditions before being distributed to zonal stores. s. The zonal stores then distribute the vaccines to states and LGAs, which finally deliver them to health facilities and end-users. It is also good to note that data flows in the opposite direction, from the health facilities to the national (GOVT 1)

After the procurement, the vaccines will come by flight (due to their sensitivity) and it is received at the airport.  Our National dry and cold store is at the airport both in Lagos and Abuja respectively). It is received at the walking cold room and when it is confirmed based on the forecast how much was provided by the manufacturer, it is distributed along sides with its complimentary commodities (syringes and safety boxes) to the state. Notably, some states have zonal stores – the vaccines come from the National to the state, the state to the LGA store, and then from the LGA store to the health facility.  All the health facilities have solar refrigerators.  The vaccines are kept in solar refrigerators and removed based on their target population of a particular day.  (Partner 1).

Challenges to COVID-19 Vaccine Distribution and Delivery to the Last Mile

Table 2: Challenges to COVID-19 Vaccine Distribution and Delivery to the Last Mile

The study identified and classified the challenges in COVID-19 vaccine distribution and delivery systems to the last mile into three major categories: (1) Individual, Societal and Cultural Challenges, (2) Environmental Challenges, and (3) Systemic Challenges. The categories of the challenges are as shown in Table 2.

Systemic Challenges

Poor Data Management and Visibility: Poor stock data visibility and weak vaccine accountability were identified as major challenges to the management of vaccine logistics and supplies in Nigeria, especially at the lower levels of the supply chain. These challenges undermine the timely decision-making process for ensuring full stock availability and sufficiency at the last mile. In response, governments at all levels with support from development partners have developed several data management platforms in addition to routine vaccine stock-taking exercises to improve vaccine stock visibility as well as inform vaccine management logistics and supplies at all levels.

We operate a system that data visibility is an issue as well as vaccine accountability in the country. Yes, there are data management platforms in the system, but the issue is that they are not operating optimally, there are a lot of vaccine diversions that are not accounted for especially at the LGA and facility level. Another is inconsistency in keeping data on vaccine usage and supply. (Partner 1).

Capacity for Storage of Vaccines: The state of epileptic power supply for vaccine storage, inadequate storage facilities and the poor conditions of the available storage facilities such as freezers, temperature monitoring devices, etc. pose serious hurdles to vaccine access. These are existential challenges because some of the vaccines are very sensitive, like Moderna, which requires storage at specific temperatures, and Pfizer, which needs to be kept at minus 70 degrees Celsius. Maintaining these temperatures to keep the vaccines potent remains a major challenge in Nigeria’s cold chain management and logistics system as some of them lose their potency as a result of temperature fluctuations due to power issues.

One of the primary challenges involves managing the ultra-low temperature requirements of certain COVID-19 vaccines, such as Moderna, which need to be stored at -75 degrees Celsius. Our existing equipment wasn't initially capable of handling these temperatures, Ideally, there should be adequate storage facilities in every state, but this is not always the case.  (Academic 1).

Poor maintenance culture of vaccine storage equipment across national, and subnational levels of vaccine storage poses a challenge to effective storage of the vaccines. Even obsolete equipment is also kept and becomes an antiquity-blocking space (Provider 1).

Inadequate Skilled Staff: The vaccine storage and distribution system, vaccine administration and data management systems were understaffed as reported by most respondents. Personnel inadequacy poses a challenge in managing the scale and scope required for efficient vaccine distribution, delivery and storage. Also, staff is not always properly trained on how to maintain the specific conditions required for each vaccine, leading to vaccine spoilage due to improper storage in addition to suboptimal vaccine administration and data management issues.

In addition to infrastructure issues, understaffing and available ones are not always properly trained on how to maintain the specific conditions required for each vaccine, leading to vaccine spoilage due to improper storage. While we have made improvements, our system is still not optimal, particularly because of the vast size of the country and the many hard-to-reach areas, including riverine regions (Academia 1).

Government’s Contributions: Respondents revealed that lack of political will on the part of government; corruption, inefficient allocation of available resources, poor public accountability and accountability structures, lack of transparency, and procurement bottlenecks are serious and pervasive health systems menace which pose significant challenges to the massive deployment of the COVID-19 vaccine in Nigeria. In addition, some respondents mentioned that bureaucracy within the vaccine and immunization ecosystems impairs the distribution and delivery of vaccines in a timely manner. 

Insufficient Funding: Most of the time, funding for vaccine logistics and supply is provided by foreign development partners. Thus, the level of the funding is usually dependent on the programming decisions of funding partner(s). Therefore, study respondents reported the funding for vaccines including COVID-19 vaccines is usually suboptimal and is not commensurate with the needs of the population. Further, there is the concentration of funding to procure and distribute the commodities at the national and state levels with marginal provisions for the last-mile vaccine logistics.

There is little or no funding for collection and other logistics at the LGA levels to the last mile. To elaborate; there is funding to procure the vaccine, to fly it into the country and to the state store; and it stops there in most cases. Like in the south, the LGA workers have to use their money for vaccine collection. In other words, the health worker has to either use her personal income or money generated from other PHC services. There is a daunting challenge in funding vaccines for it to get to the last mile. (Partner1).

Funding is also limited with no consideration of communication, advocacy and sensitization activities:

There is limited funding for communication which hinders sensitization activities (FGD 3 respondent 7)

Environmental Challenges

Transportation and Climate: The condition of roads and other transport infrastructures as well as the weather vagaries significantly impact the transportation of vaccines. One respondent mentioned the in order to ensure a more effective transportation of vaccines, that the government outsources the internal distribution different subnational to third party logisticians. Although it has been observed that there are inherent capacity issues which has still resulted to vaccine wastages.

A journey that should take a short time can be extended due to these conditions. Bad roads and harsh weather contribute to compromising the vaccine efficacy by the time it arrives at its destination. This issue is crucial because it affects the integrity of vaccines, especially those requiring strict temperature controls. (GOVT 2).

Displacements, Hard-to-Reach Populations and Insecurity: Reaching displaced or otherwise inaccessible (Hard-to-Reach) populations with life-saving commodities remains a significant hurdle in the country. Security challenges, such as conflicts, religious insurgency and invasions caused by cattle rustlers and bandits, as well as logistical challenges in riverine areas without proper vehicular access, severely hinder efforts to deliver vaccines to the affected groups and communities.

Individuals living in remote or hard-to-reach areas face significant challenges due to the poor state of roads and limited health facilities. These geographical barriers severely affect their ability to receive vaccines timely (CSO 1).

Those who are displaced due to conflict or environmental factors often lack stable access to healthcare services, making it difficult to reach them with regular public health interventions, including vaccinations (Academia 1).

Individual, Societal and Cultural Challenges

Myths and Misconceptions: Superstitious and cultural beliefs posed a major challenge to vaccine access by individuals. Additionally, resistance from community leaders who do not fully support vaccination efforts due to misconceptions or misinformation about the vaccines exacerbated this challenge:

A lot of misconceptions regarding the side effects that cause health impairment, the rumor that the vaccine was made to eliminate the black population, misconception that it was not properly tested before commercialization, that the quality of the brand for the white was different from those sent to the blacks were reported from field as part of the reasons who low uptake of COVID 19 vaccination (Health worker 2).

Poor Access to Prompt Information: A major obstacle to equitable vaccine access is the dearth of up-to-date relevant data on vaccine supply and availability, distribution patterns, etc. The poor access to real-time information contributes to vaccine logistical and delivery operations which exacerbates inequitable and hesitancy.

Vaccine Hesitancy: Vaccine hesitancy was another significant challenge to vaccine access, influenced by cultural beliefs and conspiracy theories, some of which originated from the different parts of Nigeria, as stated by a respondent.

Surveillance Systems Challenge: Report from the government respondents indicated that the disease surveillance system in Nigeria is suboptimal. It was temporarily improved during the COVID-19 pandemic but has since diminished. There was a geospatial mapping initiative that allowed the government to locate households with the virus or individuals who had been vaccinated. This approach facilitated follow-up based on the geospatial data, helping to identify where individuals had travelled, where vaccinations had occurred, and areas with low vaccination rates. As part of the follow-up programme, respondents were informed that there exists a desk for Adverse Events Following Immunization (AEFI) and Adverse Events for Vaccines of Special Interest (AESI).

One major problem with the surveillance systems as mentioned by a respondent is the challenges faced by the registration system. The mobile application used to register people who were vaccinated sometimes malfunctions making it difficult to send real-time data to the cloud database. Therefore, differences exist between the number of persons immunized and the number reported in the database.

Stakeholders in COVID-19 Vaccine Distribution and Delivery

Table 3: Stakeholders in COVID-19 Vaccine Distribution and Delivery in Nigeria

Several actors were identified by respondents to have played and still playing significant roles in the COVID-19 vaccine distribution and delivery ecosystem in Nigeria. Table 4 below shows the different stakeholders, their level of participation and their specific roles as identified by respondents.

The table 3 shows the different actors in the vaccine (including COVID-19 vaccines) distribution and delivery system. The actors include but are not limited to governments at the national, state and LGA levels with their respective MDAs including the FMOH, NPHCDA, NCDC, Custom services, SON, NAFDAC, etc. The government at the federal level is responsible for developing the vaccine program which is adapted at the state level to suit their local context, forecasting and support with counterpart funding for procurement and logistics, handling, storage of the vaccines at the federal and zonal levels and surveillance.

The regulators at the national levels are responsible for testing and approval of the vaccines to meet the required standards. The presidential committee on COVID- 19 which is made up of policy makers, private sectors, partners (donor and implementing), CSOs, legislators, Judiciaries, researchers and academics was responsible for development of implementation plans, SOPs, strategies etc. At the state and LGA levels, the government through their respective MDAs support development of strategies and plans, implementation including micro plans, support with storage, handling and distribution of the vaccines and commodities at the state and LGA levels.

The actors involved are but not limited to National Airport, NAFTDAC, NPHCDA, NCDC, WHO, UNICEF, GAVI, AFRINET, WHO, Private sectors including TPA and manufacturing pharmaceutical Industries (GOVT). The vaccination program for Nigerians was developed by the National Primary Health Care Development Agency (NPHCDA). The Ministry of Health is also involved in these efforts. GAVI supplies the vaccines, with additional support from donor partners such as WHO and UNICEF. During the epidemic, there was significant involvement from both the public and private sectors in the distribution process. Currently, COVID-19 vaccination has been integrated into routine immunization practices. The same mechanized approach used for routine immunization is being advocated to expand the reach of COVID-19 vaccination (Academia 1)

Partners identified in the study within the vaccine distribution and delivery ecosystem include the WHO, GAVI and UNICEF. Their core mandate in the system was to procure the vaccines for the country based on forecast results. They also support the federal government through the provision of funding for distribution and other logistics in the delivery of the vaccination. On its part, UNICEF has focal officers in each zonal and state cold chain store who support the Cold Chain Officers in the implementation of cold chain activities across all zones and states across Nigeria.

Most vaccines are donor-driven, particularly by GAVI and other donors. Once purchased, the Ministry of Health, along with the NPHCDA (National Primary Health Care Development Agency), takes charge. The vaccines are then distributed to the state primary health care facility (SPHCDS). However, not every state has optimal storage facilities. From there, the vaccines are further distributed to local governments and primary health care centers at the ward level. (Academia 1)

The Partners involved also played supervisory roles and provided funds to incentivize those involved in the vaccination, although not all workers confirmed receipt. (HCW 1)

Private sectors including the pharmaceutical and manufacturing companies, the third-party agents (TPAs) who are responsible for producing the vaccines ensure that best practices are adopted in the freight of the vaccines, distribution of the vaccines between national cold and dry stores in Abuja and Lagos, respectively to the six zonal cold stores, and between the zones to the satellite and state cold stores, and finally, to the LGAs through the TPAs.

The public and private health providers at the tertiary, secondary and primary levels were also part of the important actors whose roles were to deliver the vaccines to the end users. Additionally, they generate vaccination and coverage data for decision-making through registration and uptake reports, as well as report any adverse event from the vaccines to the surveillance officer of the government who ensure that the responsible trained doctors are detailed to the facility to manage the incident. Another key actor in the COVID-19 vaccination space as identified by respondents is the CSOs who monitor and check the implementation of the program to ensure that it is people- and population-centric. According to a government respondent, the CSOs also participated in sensitization of the masses - supporting the ministries of information and communication in creating awareness of the need for positive behaviour and vaccine uptake. The research institutions and the academia were central in the vaccination space of COVID-19 and other vaccines, as they provided evidence for decision-making and supported the development of vaccination plans and intervention strategies.

Gender Considerations in Distribution and Delivery of COVID-19 Vaccines

Across all respondent groups, the interview result showed that it was difficult to determine which gender participated more in the distribution and delivery of vaccines including COVID-19 vaccines. However, a respondent from the government parastatal reported that although is difficult to determine, for some states like Enugu in the southeast, Kaduna in the north-west and Niger in the north-central, their zonal stores have a ratio of 1:5 for male and female, respectively. In the process of handling vaccines and commodities, males are always engaged as ad hoc staff.

Generally, health workers are more women; in situations where we have men, those men either work as ad hoc staff or messengers, cleaners or security and heavy-duty lifters (Partner 1)

Challenges and Strategies to Improve Coordination

The Federal and State governments through the Federal and state Ministries of Health and their respective parastatals especially the NPHCDA and SPHCDA have the National Logistic Working Group (NLWG) for Vaccines and Related Commodities. The NLWG comprises representatives of the FMOH, NPHCDA, NCDC, development partners national and local implementing partners, the private sectors including manufacturers, TPAs, health facilities, CSOs, and the academia.

The agency has the National Logistic Working Group (NLWG), which comprises both the agency partners, the country partners, and other government officials. The NLWG comes together to discuss and make decisions to best resolve issues (GOVT 1).

The function of NLWG is to perform advisory, coordination and oversight functions over all activities regarding vaccine procurement and logistics including distribution and delivery to the last mile.  However, the body is faced with the challenges of inadequate funding to conduct the monthly and quarterly meetings. Again, the bureaucratic process of securing approvals for urgent activities proves very unfavorable to handling vaccines with speed.

For manufacturing, importation, distribution and transportation, the NPHCDA involves the private sector operators including third-party logistic firms, which function to transport and deliver the vaccines respectively from the strategic stores to the zonal and state stores. However, conflicts of interest seem to hamper the delivery of vaccines and proper management or the associated activities. In an attempt to make a profit, vaccine handling during transportation might not be properly conducted.

The absence of relevant policies and frameworks to monitor the distribution and management of vaccines by the private sector was identified as an important gap in the vaccine distributive chain. The government is expected to develop and implement policies, plans and frameworks to monitor the distribution processes and management of COVID-19 vaccines. Also, the limited involvement of the private sector in the National and State Technical Working Groups will result in reduced interest in the conditions of the vaccines during handling especially during transportation. Finally, another challenge in ensuring effective participation of the private sector and CSOs is the huge taxes and other government regulations. These limit the participation of the private sector within the vaccine distribution and delivery space.

Between the arrival at the national cold store and the actual vaccination, vaccines including COVID-19 vaccines pass through several logistical stages. The vaccine distribution and delivery mechanism in Nigeria operates at majorly five different levels: national level, regional level, state level, LGA level and health care facility level. This is corroborated by a study by Lee Connor (Lee, Connor, Wateska, Norman, Rajgopal, Cakouros, et al., 2015). Nigeria’s cold chain system consists of five levels reflecting this administrative structure as follows: A National Strategic Cold Store is the first storage location for all vaccines including COVID-19 vaccines after arrival from manufacturers abroad. This in turn supplies six zonal stores, located in one state each of Nigeria’s six geopolitical zones. Each zonal store then supplies states within its zones. LGA stores collect their vaccines from their state store, while primary health care centers collect their vaccines from their respective LGA store This is similar to the findings from a study in 2017 (Sarley et al, 2017).

The poor maintenance of available CCEs in the cold stores across the county impacts negatively on vaccination coverage. This indicates that preventive maintenance to avoid equipment failures is rarely executed, spare parts are often not available, and repair of cold chain equipment is rarely done promptly. As a result, vaccines are exposed to dangerous temperature fluctuations, rendering some of them unusable and resulting in vaccine wastage or impaired vaccine efficacy. To deal with these issues, solar-powered refrigerators have proven to be highly efficient with low energy consumption, although they require properly trained personnel for installation and maintenance (Chen et al., 2015).

Transportation of vaccines between levels is done using a variety of transportation modes. Between higher levels, vaccines are often delivered using airplanes, cold trucks and trucks. At lower levels, the preferred transportation mode depends on the road conditions and the accessibility of the facilities. Reported transportation modes at lower levels include trucks, public transport, third-party vehicles, motorcycles, bicycles, and carrying vaccines on foot as was reported in a study conducted by Comes (2018). Due to transportation disruptions including bad road conditions, transportation durations are unreliable making it difficult for timely delivery of the vaccine and remote areas can be very hard to reach which is similar to the findings of a Belgium study which stated that bad road is a factor that contribute to untimely delivery of vaccines (Kaucley and Levi, 2015).

During transportation, vaccines need to be kept at specified temperature ranges. This implies the need for adequate cold chain distribution equipment, which is especially challenging for the last-mile logistics (Azimi et al, 2017). When refrigerated trucks are not available or not appropriate, vaccine carriers and cool boxes are used to keep the vaccines cold during transportation as reported in the study. On the one hand, vaccine carriers can be used to transport a small number of vaccines for a limited time (up to a few hours; this might result in vaccines losing their potency causing wastage if the time is too long.

The need for more effective transportation of vaccines resulted in the government outsourcing some parts of vaccine distribution to third-party agents/logisticians. This resulted in improved performance and decreased costs in comparison to a government-run distribution system. However, conflict of interest and capacity issues persist in the system causing vaccine wastages and loss of potency as a result of exposure to unfavorable temperatures and weather vagaries. In an attempt to assuage vaccine wastages during distribution, there is a need to execute partnership MOUs with the TPAs to ensure proper handling of vaccines during transit, as well as provision of training for logistics officers of the TPAs, as well as improved funding to serve as incentives for performance. There is also a need to develop policies for monitoring and supervision of vaccines during transportation to ensure proper handling of the vaccines by the TPAs.

The final step of the distribution and delivery is the actual vaccination. routine administration of vaccines is traditionally carried out at regular immunization sessions, during outreach actions, or through immunization campaigns but that of COVID-19 was done during the outbreak through the COVID-19 vaccine campaign and it ended afterwards due to stoppage of supply. The study reported that some people were not reached due to accessibility issues including environmental issues like distance, and insecurity, and those whose communities were displaced as a result of conflicts. The other reasons for inequitable access to COVID-19 vaccines during the campaign were religious beliefs, misconceptions and conspiracy theories.

According to the study respondents, the key stakeholders and actors that played roles and were still relevant in the COVID-19 vaccine distribution and delivery systems include but are not limited to the Presidential Task Force on COVID-19 response, the FMOH, the FMOI, NCDC, NPHCDA, NOA, private sector operators, development partners, donors and local implementing partners, SMOH, SPHCDA, CSOs, health facilities, communities. These actors made significant contributions towards ensuring that the vaccines reached the last mile and were delivered to the final recipients. However, the involvement of these stakeholders especially the private sector entities and CSOs faced some challenges. For example, despite the government’s oversight functions described above, there exist suboptimal quality standards in handling the vaccines during transportation and even in vaccination activities. Therefore, a key lesson learnt is the importance of a licensing process for private facilities and incorporating them into the immunization system’s regular supervision and quality assurance exercise to ensure compliance with official guidelines and policy. In addition, the experience from the study demonstrates the importance of incentivizing private sector providers to be accountable for quality services in the distribution and delivery system. This can be achieved by their taking part in regular planning, training, reviews and decision-making activities.

Again, the need was identified for the government to show commitment to developing and expanding national guidelines with a strategy for improving public-private collaboration in vaccination delivery, which may include non-monetary incentives such as awards, public recognition, etc. and in-kind/monetary support including defraying operational costs, salaries, transportation and supply of cold chain equipment).

The COVID-19 pandemic generated a substantial quantum of misinformation across the world which contributed to vaccine hesitancy. Strategies to refute and forestall the occurrence of infodemics (massive mis/disinformation orchestrated through social media) can leverage the activities of CSOs. These not-for-profit organizations have demonstrated proficiency in promoting behavioral change as evidenced by previous contraception and vaccination campaigns, and more recently for COVID-19 protocol implementation. They possess the capacity to use community-driven communication and intervention strategies to promote the personal and public health benefits of vaccination. They are also cognizant of the cultural and religious sensibilities, customs and community norms, to achieve behavior and attitude change.

During vaccination campaigns, CSOs should play more prominent roles in monitoring national vaccine governance programmes to ensure equitable distribution. Gross mismanagement of vaccines causes delays that can lead to vaccines expiring and being wasted (Taylor, 2021). Monitoring and supervision of vaccine handling and storage by CSOs and private sector operators will improve their sense of belonging and improvement in the logistics and and storage systems.

Strategies for Equitable Distribution and Delivery of COVID-19 Vaccines

Establish vaccination camps close to hard-to-reach areas, providing security for vaccinators, and offering incentives for those involved in the vaccination process.

Strengthen the ward development committees (WDC) to ensure accountability and transparency are maintained at the primary health facilities.

Community heads and gatekeepers through ward development committees should be actively involved in vaccine advocacy and sensitization for communities to access vaccination.

Micro plans for COVID-19 should be reviewed and implemented with funding earmarked for review meetings for micro-plans and other tools that facilitate vaccination.

COVID-19 vaccination stopped after the acute phase of the epidemic, due to the halted supply and funding for logistics. Therefore, the government should allocate adequate supply and funding to ensure continuous vaccination against COVID-19.

On-the-job trainings across the different levels of vaccine distribution and delivery including the CCOs, VCMs, health workers, logistics officers and TPAs on vaccine management, vaccine accountability and vaccine administration.

The government and other relevant actors across different levels should prioritize implementation of monitoring and supervision activities of the different actors and components of vaccine procurement, distribution and delivery.

Employment of qualified personnel across the different vaccine distribution and delivery systems including logistics officers and health workers.

Strengthening the cold and dry stores at different levels with relevant infrastructures, human resources, training, and funding to facilitate effective and efficient handling of the vaccines and associated commodities.

Detailed vaccination schedules, for members of vulnerable groups and hard-to-reach areas, to access vaccines in their PHC.

Validators should be involved in surveillance; there should be continuous monitoring in the field to generate data for decision-making and planning to improve vaccine delivery system. There should be collaboration between the federal and state governments, CSOs and private sector companies would ensure that there are incentives for the private sectors and CSOs through adequate funding and recognition to prevent conflict of interest and unethical practices.

This study provides information on equitable distribution and delivery of COVID-19 vaccines in Nigeria. We used a qualitative approach, which allows for the assessment of the timely development and deployment of interventions for COVID-19 vaccination. The conclusion is plausible that measures to enhance equitable COVID-19 vaccine acceptance and uptake must address the challenges related to accessibility and misinformation while strengthening coordination and partnership mechanisms to improve availability, supply chain logistics infrastructures and management systems across the country.

Limitation

A good number (31%) of participants initially mapped for the interviews turned down the appointments while some of those that were interviewed refused their responses to be audio recorded which made the interviewers rely on individual abilities to capture the discussions as much as they could, which did not enable complete information recall.

All interview transcripts were coded by the same research team who conducted the interviews and no double coding was utilized to verify results. Finally, the study’s data collection strategy elicited information about participants' activities during the pandemic; the respondents could have suffered from poor recall or unconscious bias in their responses.

Conflict of Interest

The authors declare that they have no competing interests.

Author Contributions

Chikezie Ifeanyi, Emmanuel Okechukwu and Hyacinth Ichoku conceptualized the study, Chikezie Ifeanyi, Emmanuel Okechukwu, Olushola Tosin and Hyacinth Ichoku collected data, Chikezie Ifeanyi analysed the data and drafted the first manuscript. All authors reviewed and approved the final manuscript. 

Funding

The research from which this manuscript was written was funded by AFHEA/WHO Special programme for research called Equitable Access to the COVID-19 Vaccines in Africa” (ECOVA) project. However, the views expressed in the manuscript belong solely to the authors and do not reflect those of the funders.

Acknowledgments

Our sincere thanks to the stakeholders of research evidence who participated in this study and shared their experiences and learnings.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.