How Kenya and parts of Nigeria increased vitamin A supplementation to historic highs – even during COVID

Access to critical health care declined around the world during the COVID-19 pandemic – with a few important exceptions.

Notably, vitamin A supplementation coverage in a few geographies soared. In Nigeria’s Nasarawa State, for example, vitamin A supplementation coverage roughly doubled over three years. Similarly, Kenya’s vitamin A supplementation coverage during the pandemic reached 86%, a more than 25% increase from pre-pandemic highs and a historic milestone.

The strategies, adaptations, and lessons that drove these successes may be of interest to health leaders working to close the gap in their delivery of vitamin A and a host of other critical health services. Vitamin A is essential for the immune system and the healthy growth and development of children. Vitamin A deficiency is the leading cause of preventable childhood blindness and increases the risk of death from common childhood infections, such as measles and those causing diarrhea.

In Nigeria’s Nasarawa State, the challenges posed by the pandemic forced Dr. Absalom Madawa, who has been serving as director of primary health care for the Nasarawa State Primary Healthcare Development Agency and leading the vitamin A supplementation efforts since 2014, to “think outside the box.”

“Vitamin A supplementation in Nigeria is not done routinely. It is done in a campaign mode and that happens every six months in May or June and November or December of every year. We call the campaigns 'MNCH Week' – Maternal Newborn and Child Health Week,” said Dr. Madawa. “During MNCH Week, we intensify demand generation and social mobilization activities, so you'll see the facilities getting filled up with mothers bringing their children for supplementation. During the pandemic – and for obvious reasons – we couldn't encourage large groups of healthy people to come to the health facilities and wait for services. Many other states did not deliver vitamin A or deworming to their children during the pandemic. Since we felt the need to reach our children with these services, we decided to change our usual strategy. Instead of getting the children to come to the facility, we deployed teams to take the service to them in their homes."

To make that happen, his agency trained and launched 1,380 mobile two-person teams, most of whom were Community Health Influencers, Promoters, and Service agents (Nigeria’s CHIPs program) to go house to house delivering vitamin A supplementation. Before the pandemic, there were fewer than 30 such teams.

An additional 461 special mobile teams were trained and deployed to serve hard-to-reach communities with vitamin A supplementation. Dr. Madawa and his colleagues also increased the number of supervisors supporting those teams, including monitors representing partner organizations, to between 10 and 22 in each of the state’s 13 local government areas. And they tasked the CHIPS agents with informing parents about the importance of vitamin A supplementation to reduce child mortality and blindness in advance of and concurrently with vitamin A distribution efforts. Town announcers were hired to announce the dates, times, and locations of the mobile units.

With the goal of identifying other unexpected barriers, they launched their first post-event coverage survey with support from Helen Keller Intl. The survey provided Dr. Madawa and his colleagues with surprising information. “Right in my own city, in the capital of our state, we found that there were people completely unaware of vitamin A supplementation efforts,” he said. “They are neighbors of mine. But they were unaware. The survey gave us data we could use to make improvements.”

Based on that data, they expanded public service announcements in local languages to radio stations that are based in neighboring states but are popular within Nasarawa state. They also increased the number of television stations playing public service announcements. And the team began engaging religious leaders through an interfaith forum, to create more awareness. Today, they have amassed a database of more than 10,000 Christian and Muslim religious leaders who are contacted in advance of any supplementation activities in their area and provided with health messaging to share with their followers.

The special mobile teams proved so successful during the pandemic that they have since expanded from 461 to 550 and the number of health workers on each of those teams has risen to help them meet demand. At the same time, with health facilities reopening, the 1,380 house-to-house teams have been disbanded without a significant decline in vitamin A supplementation coverage.

Next door, in Nigeria’s Benue state, a post-event coverage survey, also launched for the first time during the pandemic with support from Helen Keller Intl, helped health leaders identify four key bottlenecks: poor community mobilization; late and insufficient commodity supplies; insecurity and communal clashes making some communities inaccessible; and disruptions from competing interventions, notably a COVID-19 mass vaccination drive in a different location on the same day. In response, the state's Primary Health Care Development Agency led other government agencies and NGO partners to solve these bottlenecks. As a result, the post-event coverage survey following the June 2022 campaign indicated that coverage had increased from 68% to 93% – a historic high.

Kenyan health authorities were also able to shift their strategy and adopt post-event coverage surveys to identify barriers and increase their coverage rates during the pandemic. “When the pandemic first hit, we had some shock,” recalled Julia Rotich, who leads micronutrient efforts for Kenya’s Ministry of Health. “Schools and early childhood development and education centers were closed, and no one was going to health facilities lest they contract COVID. So, our two main distribution channels were closed. There was a lot of fear. But we knew we needed to do something.”

With support from partners, Kenyan authorities developed a new plan. Thousands of the country’s community health promoters (CHPs) would be trained and equipped with personal protective equipment (PPE) to map all of the households in their community and promote vitamin A supplementation to all families with young children in their communities. And the CHPs would accompany community health assistants (CHAs), both wearing PPE, as they traveled house to house to deliver vitamin A supplementation. Authorities quickly developed interim guidelines to help the CHPs and CHAs understand how they could deliver vitamin A and health promotion messages while keeping themselves and their community safe.

All health system planning meetings to support this massive shift were moved online and moved from monthly to sometimes as often as weekly. County-level WhatsApp groups shared challenges and successes. Community mobilization was increased, including engagements with chiefs and the use of FM radio public service announcements. Health leaders also piggybacked on existing ongoing polio campaigns and added vitamin A supplementation to them. Lastly, and critically, each county in the country had the dedicated and focused support of at least one partner organization.

By the end of 2020, Kenya's health leaders thought they had achieved their goal. Their administrative data indicated a national coverage rate above 90%. But when authorities piloted their first post-event coverage survey in two counties, officials were dismayed to learn that actual coverage rates were as much as 30% lower. Trans Nzoia county, for example, recorded a coverage rate of 128% based on its administrative data. But the post-event coverage survey found the actual rate was 81.6%. And in Bungoma County, the administrative data had indicated a 119% coverage rate. But the post-event coverage survey found a 90% coverage rate. While disappointing, the survey provided much needed accuracy and gave them a roadmap for improving their coverage by helping them identify and locate barriers to care and improving data quality.

“The biggest barrier identified is knowledge of the importance of and availability of vitamin A,” said Esther Njeri Waithera, Helen Keller Intl’s program coordinator in Kenya. “We found people who live right next to a health facility and don’t know about vitamin A or bring their kids for vitamin A, although it is free and available right next door.”

By 2021, the post-event coverage survey indicated they had reached 86%, only five percentage points lower than the administrative data, and an all-time high point for the country.

“There is a compelling story here in the fact that by reacting very rapidly and changing our ways, Helen Keller Intl teams supported government partners to maintain this vital service for children, when most other services were severely disrupted, without causing any harm,” said David Doledec, Program Director of vitamin A supplementation for Helen Keller Intl.