The aircraft pointed its nose gently towards the runway at Sadiq Abubakar III International Airport, Sokoto, bathed in the warm Sunday morning sun. Sokoto was like that distant relative your parents talked a lot about, but whom you had never met; my father had spent his National Youth Service year in Sokoto and loved to regale us with tales of the place. Of how in the dry season, it was so hot, they had to soak their mattresses with water, to be able to catch a few hours’ sleep, then wake up and repeat. And in the harmattan, it was so cold, that if you left your bucket of bathing water outside and went into your room to pick something, the water would be halfway to frozen by the time you returned. I always secretly thought his stories suffered from a little too much embellishment. I was about to find out, as Sokoto beckoned to us with beckoned with open arms.
I was in Sokoto at the behest of my friends and colleagues, Adebiyi Olusolape and Dr. Tosan Mogbeyiteren, founders of Black Swan Technologies, who were carrying out a pilot of their mHealth intervention, WeMUNIZE, to visit the project and write a creative non-fiction piece on its implementation. WeMUNIZE was designed to answer some of the problems militating against childhood immunization, and to drive its uptake in Sokoto. This pilot was being generously funded by USAID.
My father, he underestimated the heat, or he failed to communicate its real intensity to us. Standing in the sun was to discover that it was a toothed entity, eager to sink its fangs into any patch of exposed skin without mercy. Nevertheless, I had to brave the sun to visit some of the health facilities implementing WeMUNIZE. Sokoto state, with an immunization completion rate of 1%, and a DPT 3 coverage of 2.6% among children between the ages of 12 and 24 months*, is one of the worst performing states, in a region that largely falls short of immunization coverage targets – 80% coverage is the recommended target for states. Immunization coverage in Nigeria is beset by many problems, affecting both the demand for, and the supply of immunization services. In addition to problems experienced all over the country – unreliable power supply to maintain vaccines within the narrow temperature range of 2oC – 8oC required to preserve potency; inadequate human resources for service delivery; a fear of side-effects leading to cases of drop-outs, especially after the first dose of DPT – the north has a history of resistance to immunization, arising from lack of trust in the process, and fanned by religious and cultural biases. Thus, innovative ways of increasing immunization uptake are always in demand.
One of the reasons for reported low coverage of immunization is that the surveys from which data is generated often depend on parents’ and caregivers’ ability to show evidence of immunization in the form of immunization cards. Most caregivers, especially in the rural areas are often unable to produce documentary because the cards are either torn or missing. Black Swan sought to overcome this problem by providing a clear plastic bag with a barcode for each child, so that their parents can safely keep the card and other immunization-related documents, such as pictures taken at visit, and prevent loss or damage.
Other features of WeMUNIZE include robocalls and SMS to parents of children enrolled on the platform to remind them of clinic appointments; a unique identification barcode on waterproof clear bags which when scanned at the clinic, calls up the child’s details from the database, including vaccines already received and those the child is due for; an immunization database that allows providers to immediately detect which children have missed a scheduled immunization, at the end of each session, for immediate follow up; and the opportunity for each child to have their picture taken after receiving vaccinations at each visit. This last inclusion was designed as an incentive. Many immunization and interventions incentivize each clinic attendance for vaccination with token such as baby soap or other practical items for the care of the baby, to encourage completion of the immunization schedule. Indeed, many public health interventions often include incentives to increase acceptance by the target population. Black Swan decided to incentivize with something that has never been tried before – pictures. They were not extraordinary; colored pictures printed on plain paper at the immunization point. Yet they were a massive hit.
Many parents and caregivers reported attending immunization sessions solely for the pictures. In choosing pictures, Black Swan had chosen an incentive with a strong emotional pull, one that parents found it very difficult to ignore, especially parents from semi-rural and rural areas. Apparently, in these areas, children rarely get their pictures taken and especially not children in the age range being vaccinated i.e. below the age of one. Not only was Black Swan providing them with pictures of their children, they were being taken at every vaccination visit. Thus, they had pictures of their children at different ages, with evidence of growth. So great was this pull, that one parent, on discovering that her clear bag was damaged, borrowed her neighbor’s own. She could not risk not be attended to without the bag, and so preferred to present her neighbor’s own, rather than miss a session and a photo opportunity. She wasn’t aware that the bag was unique – when the barcode was scanned, it pulled up details of a child who had completed his immunization schedule.
WeMUNIZE illustrates many things about the Nigerian immunization story; about the possibilities of tech and mobile-based interventions, and the challenges make a wonderful idea in theory vastly different from the reality – epileptic power supply meant that many mobile phones were nearly always off – their owners missed both reminder calls and text messages; caregivers supplied phone numbers of the only family member with a mobile phone. In many cases, that family member lived and worked in a different town from where the child and caregiver live – reminder messages were lost in transmission. The roaring success of its picture incentive however, provides an opportunity for project planners to give some thought to the kind of incentives included in development packages.
Because sometimes, emotion trumps practicality.