Routine Immunization Consultant Program in Nigeria: A Qualitative Review of a Country-Driven Management Approach for Health Systems Strengthening

BACKGROUND Since 2002, the Nigerian government has deployed consultants to states to provide technical assistance for routine immunization (RI). RI consultants are expected to play a role in supportive supervision of health facility staff, capacity building, advocacy, and monitoring and evaluation. METHODS We conducted a retrospective review of the RI consultant program's strengths and weaknesses in 7 states and at the national level from June to September 2014 using semi-structured interviews and online surveys. Participants included RI consultants, RI program leaders, and implementers purposively drawn from national, state, and local government levels. Thematic analysis was used to analyze qualitative data from the interviews, which were triangulated with results from the quantitative surveys. FINDINGS At the time of data collection, 23 of 36 states and the federal capital territory had an RI consultant. Of the 7 states visited during the study, only 3 states had present and visibly working consultants. We conducted 84 interviews with 101 participants across the 7 states and conducted data analysis on 70 interviews (with 82 individuals) that had complete data. Among the full sample of interview respondents (N = 101), most (66%) were men with an average age of 49 years (±5.6), and the majority were technical officers (63%) but a range of other roles were also represented, including consultants (22%), directors (13%), and health workers (2%). Fifteen consultants and 44 program leaders completed the online surveys. Interview data from the 3 states with active RI consultants indicated that the consultants' main contribution was supportive supervision at the local level, particularly for collecting and using RI data for decision making. They also acted as effective advocates for RI funding. In states without an RI consultant, gaps were highlighted in data management capacity and in monitoring of RI funds. Program design strengths: the broad terms of reference and autonomy of the consultants allowed work to be tailored to the local context; consultants were often integrated into state RI teams but could also work independently when necessary; and recruitment of experienced consultants with strong professional networks, familiarity with the local context, and ability to speak the local language facilitated advocacy efforts. Key programmatic challenges were related to inadequate and inconsistent inputs (salaries, transportation means, and dedicated office space) and gaps in communication between consultants and national leadership and in management of consultants, including lack of performance feedback, lack of formal orientation at inception, and no clear job performance targets. CONCLUSIONS While weaknesses in managerial and material inputs affect current performance of RI consultants in Nigeria, the design of the RI consultant program employs a unique problem-focused, locally led model of development assistance that could prove valuable in strengthening the capacity of the government to implement such technical assistance on its own. Despite the lack of uniform deployment and implementation of RI consultants across the country, some consultants appear to have contributed to improved RI services through supportive supervision, capacity building, and advocacy.