Country Ownership as a Guiding Principle for IA2030: A Case Study of the Measles and Rubella Elimination Programs in Nepal and Nigeria

"Country ownership does not mean government ownership alone. The people of the country have both a right and a responsibility towards the success of a public health program."



Country ownership, as opposed to donor-driven development, is a principle that recognizes the centrality of countries' leadership, systems, and resources in executing programmes and achieving sustainable development. In alignment with this notion, the Immunization Agenda 2030 (IA2030) was developed with country ownership as core to the 10-year plan. The operational architecture of IA2030 - the monitoring and evaluation framework, the ownership and accountability mechanisms, and the communication and advocacy strategy - have been developed by systematically applying this principle. This paper illustrates how two countries, Nepal and Nigeria, have exemplified country ownership in their measles and rubella elimination programmes and discusses the ways in which country ownership drives system performance and sustains programme efforts.



The challenges and barriers of Nepalese and Nigerian immunisation programmes have been extensively covered in other publications. The qualitative data collected from the document analysis were subjected to thematic analysis to identify patterns and themes related to country ownership, specifically. It does so by deconstructing country ownership into five operational principles:

1. Commitment: Commitment to public health programmes, like the measles and rubella elimination initiatives, takes many forms: programmatic/policy, political, financial, legislative, and societal. All forms are important and mutually reinforcing.
   • Nepal: For example, government commitment is illustrated by the uninterrupted delivery of immunisation services during the period of insurgency between 1996 and 2005, leading to improvements in vaccination coverage. Notably, within the same period, several polio campaigns were conducted, and measles campaigns were implemented. Thus, political change in the country scarcely affected commitment to public health programmes, including the measles and rubella elimination programme.
   • Nigeria: For example, the 2017/2018 measles vaccination campaign is a good example of the multi-level funding support from both the federal and state governments.
2. Coordination: When a programme is country owned, the government plays a coordination role by convening the partners, setting the agenda, and providing leadership.
   • Nepal: For example, the work plan is an important instrument of coordination, especially if it is jointly developed and transparently monitored.
   • Nigeria: For example, the National Measles Verification Committee evaluates the successes or failures of key strategies related to the verification of the elimination process in the country.
3. Capacity: When a programme is country owned, it should have adequate numbers of national and sub-national staff with the capacity and expertise.
   • Nepal: For example, civil society organisations (CSOs) like the Rotary Club and the Nepal Red Cross Society assist by providing additional boots on the ground for community mobilisation, awareness creation, and campaign implementation monitoring.
   • Nigeria: For example, the United Nations Children's Fund (UNICEF) provides technical assistance in advocacy, communication, and social mobilisation (ACSM). After many years of capacity building of government officials on demand creation, a well-established ACSM structure for information dissemination at the grassroots level now exists across the states in Nigeria.
4. Community participation: Active community participation should be encouraged throughout the project implementation cycle and entails the intentional engagement of representatives of various groups, such as ethnic groups, trade groups, and interest groups, in activities where they not only provide ideas, but also partake in intervention delivery. The use of participatory approaches, like human-centred design (HCD), should be prioritised. Engagement and feedback from the end-users can help overcome local challenges and maintain implementation of programmes. Project design, planning, and implementation can be improved using local knowledge. Participation also increases project acceptability and equity in the distribution of benefits. It promotes local resource mobilisation and positions the project for sustainability.
   • Nepal: In 2012, Nepal launched the Full Immunization Declaration (FID) initiative, designed to increase community ownership and commitment to routine immunisation at the village development committee (VDC) level. Through this initiative, health care workers and female community health volunteers (FCHV) in each VDC would line list all eligible children and ensure they complete the full immunisation schedule. At the local level, mothers' groups ("Ama Samuha") and other CSOs were involved. FID would be proclaimed by a celebratory public gathering at the VDC where local leaders would sign a public commitment to maintain full immunisation status and commit local level resources toward it (see above).
   • Nigeria: In Nigeria, there is community participation at all levels. For example, in the 2017/2018 measles vaccination campaign, town announcers, community, and house-to-house mobilisers were selected from the communities where they lived and thus were well known to the communities. At the district and sub-national levels, there are social mobilisation committees whose goal was to improve acceptance of immunisation activities, meeting at least once a month and using WhatsApp groups to improve coordination and information sharing.
5. Accountability: Each stakeholder group - government policymakers, programme managers, service providers, CSOs, community leaders, religious leaders, etc. - have shared and unique roles in advancing the measles programme.
   • Nepal: Social accountability by communities was a strong feature in the Nepalese programme.
   • Nigeria: Nigeria's immunisation policy features mutual accountability between the federal government, states, local government associations, donors, and partners.

As noted here, community participation (#4, above) "is a central pillar of country ownership. The people of the country have both a right and a responsibility toward the success of a public health programs. The measles program should engage a broad base of stakeholders, including civil society organizations, to support demand creation, community mobilization, and advocacy." In addition, accountability is a key component of country ownership. Accountability should be at all levels: national, sub-national, facility, and community.



In conclusion, the researchers hope that these examples from Nepal and Nigeria show what is possible and how country ownership can be promoted and supported, given its importance to achieving immunisation goals. "The ultimate proof of operational resilience of the national immunization programs will come from achieving and sustaining at least 95% coverage with two doses of MR [measles and rubella] vaccine in every municipality and state."