Cash for vaccines: How a reward program boosts child immunization in Nigeria(PART 2)

Raising awareness about the importance of immunization and vaccines  in preventing diseases and deaths is a good step. However, one organization believes that is not enough, so it includes cash incentives in its programs for communities in Nigeria. This is the concluding part of a two-part series detailing the impact of this combined strategy. Read part one here. 

Durum, Bauchi State:  “Assalamualaikum,” or “Peace be unto you,” greets Saleh Garba Muhammed, addressing young mothers who brought their children to the Durum Primary Healthcare Centre in northern Nigeria for vaccinations on August 30, 2024.

“Remember, vaccination keeps your babies healthy and protects them from illness,” he reminds them as he lets them into the vaccination hall for the day’s immunization session.

Muhammed is the routine immunization officer at this facility in Durum, a rural community in northeastern Bauchi State. He ensures vaccine availability, child immunizations, and proper documentation.

After Muhammed’s reminder, Ibrahim Dauda, a young man in his twenties with a pouch tied around his waist, steps forward with a vaccination card to explain the immunization process, emphasizing why each step is crucial and urging the mothers to complete the schedule for their babies.

Dauda is a field officer with New Incentives or NI, a U.S.-based nonprofit that operates in Nigeria as All Babies Are Equal or NI-ABAE. NI-ABAE partners with northern Nigerian states and healthcare facilities like Muhammed’s to combat vaccine hesitancy and increase child immunization rates.

Regular reminders and vaccination messaging are essential tools that Dauda’s NI–ABAE uses to shift young northern Nigerian caregivers from vaccine apathy to acceptance, ultimately improving child health and reducing mortality.

Ignorance drives disease burden

Vaccine hesitancy due to lack of awareness remains a major challenge in key northern Nigerian states.

For instance, results from the Nigeria Multiple Indicator Cluster Survey (MICS) indicate that 37.5% of caregivers in Bauchi either never vaccinated their children or did not complete the schedule due to lack of information. It also reveals that 29.6% avoid vaccines because they lack faith in immunization.

As a result, vaccine-preventable diseases like polio, measles, pneumonia, and diarrhea remain leading causes of death among children under five in northern Nigeria, UNICEF data shows. The data also says at least 11,000 newborns die each year in Bauchi, which has a child population of 1.4 million out of 6.9 million.

Talatu Danjuma, a mother of three in Bauchi, admits that with her first two children, she did not see the need to complete their vaccination schedules, which left them susceptible to preventable diseases like diarrhea. However, when she had her last baby in early 2024, she was better informed at an NI partner facility and decided to follow the schedule.

“It’s different this time,” she says, emphasizing that her last baby is healthier.

An added motivation

While awareness campaigns help shift attitudes, a stronger motivation for young mothers is NI’s conditional cash transfer initiative, which rewards caregivers for consistently ensuring their children complete vaccination schedules.

NI-ABAE partners with state governments to boost demand for routine child immunizations in northern Nigeria. The program currently operates in 6,300 government clinics across  nine states.  It provides a cash incentive of ₦1,000 ($0.60) per routine immunization visit, with an additional ₦5,000 ($3) upon completion of all visits.

The cash incentives motivate mothers who might otherwise avoid or discontinue their children’s vaccinations.

At the Durum Primary Healthcare Centre, 25-year-old Rasheeda Umar sits patiently, waiting for her baby’s turn. A mother of two, she runs a small business selling hibiscus tea, known locally as Zobo.

“Some days I make up to ₦1,000 ($0.60); other days, ₦500 ($0.30),” she says.

Umar is one of 43 million Nigerian women living in multidimensional poverty, surviving on less than $2 a day. For her, taking a day off to vaccinate her baby at the expense of her small business could mean little or no food for the family that day. But with NI’s cash incentive, she no longer worries about missing a business day for vaccination.

“The money helps,” she says. “I used the first payment to buy clothes for my baby, and the second to collect her sister’s dress from the tailor.” She plans to use the final ₦5,000 to support her business after completing the vaccination schedule.

Mustaphar Kabir, NI’s operations coordinator for Bauchi and Gombe States, says that the consistency shown by mothers like Umar is exactly what the nonprofit envisioned when it launched the initiative.

“The program aims to ensure that all eligible children receive every required vaccination, from the first dose to the last,” he says. “We focus on reducing vaccination barriers, addressing non-compliance, and resolving issues to improve overall immunization coverage.”

The program also supports state governments in improving local healthcare facilities by ensuring proper documentation and keeping clinics active to serve the community. 

In 2023, it launched an annual awards program to recognize the best-performing Local Government Areas or LGAs.

Award categories range from Enrollment Awards for the LGA with the highest infant enrollment rate to the Penta Retention Rate Award for the LGA with the highest rate of infants returning for Penta 1, 2, and 3 vaccinations.

Other categories include the Vaccine Supply Award for the LGA with the lowest vaccine stockout ratio, the Documentation Award for the LGA with the fewest issues, and the Activities Award for the LGA with the most community engagement efforts. Top-performing managers also receive awards.

Since 2022, NI has enrolled nearly 550,000 children in Bauchi, encouraged over 8 million vaccinations, and made around 2.2 million disbursements totaling approximately ₦2.4 billion ($1,450,000) across 1,105 public clinics.

“Many children who previously did not receive routine immunizations are now coming forward for vaccination,” says Nasiru Shaibu, the Bauchi State Immunization Officer or SIO. “In fact, the number of children receiving vaccinations has nearly doubled,” Shaibu adds.

Skepticism and challenges

According to Shaibu, in many Bauchi clinics, the All Babies Are Equal program has introduced new challenges. Previously, health workers attended to an average of 15 children a day, but with the program, the number has surged to about 50 daily. This more than triples the workload for clinic staff, leading to exhaustion. 

To address this, the state government plans to enlist volunteers from the communities with health education backgrounds, who will assist with administrative tasks, manage patient flow, and support health workers during immunization sessions.

Growing concerns suggest that offering cash for vaccinations might raise suspicions among community members, who may question why financial incentives are offered for something beneficial.

However, no amount of criticism compares to the joy of seeing children grow up healthier, said Muhammed, the routine immunization officer at Durum PHC.

“It means less… typhoid, and polio—and fewer mothers burying their young children,” he adds with a big smile.