Routine immunization coverage in Nigeria has remained low for over a decade, despite
several efforts to increase it. There are significant variations in coverage between and
within states. The “Reaching every ward” strategy has been in place since 2004 to scale
up immunization activities and increase coverage. This would address aspects of the social
determinants of child health linked to access to immunization services. However, there has
been limited consideration of how the forces underlying the processes of designing and
implementing these policies intended to promote equity (such as immunization) influence
their achievements. This study explored the roles of stakeholders in the development and
implementation of the Reaching every ward (REW) policy for delivering immunization
services in Nigeria, and the factors influencing their roles. The exploration involved interviews
with policy-makers and health-care providers using a two-case study design approach, with
contrasting cases of implementation experience with the REW immunization programme.
In addition, relevant documents were reviewed. The strategy got derailed by local and
international interests and stakeholders at different levels due to weak management of the
policy change and scaling-up processes. As a result, inequities between local government
areas increased rather than decreased, which was the original objective. The study concludes
that it is possible to drive specific average and equity targets, but short-cut driven approaches
increase the risk of relapse and collapse. While involvement at the highest political level
is necessary, local-level ownership is indispensable for improving and sustaining equity in
immunization coverage.