Boosting the Immunization Workforce: Lessons from the Merck Vaccine Network - Africa

This report shares lessons learned from The Merck Company Foundation's decade of experience building immunization capacity in Africa. The Merck Vaccine Network -- Africa, a philanthropic initiative to train immunization managers in Kenya, Mali, Uganda, and Zambia, suggests seven key lessons that can help other funders, governments, and NGOs designing or implementing similar vaccine delivery training programs improve the effectiveness and sustainability of their work.Merck's experience designing and supporting the initiative can offer valuable lessons for other actors in the immunization and broader global health fields who are engaged in or planning similar work. Specifically, we identify seven forward-looking lessons that can increase the effectiveness and sustainability of programs to build the capacity of the vaccine workforce in developing countries:Conduct a rigorous needs assessment to anchor efforts in local needs and priorities;Perform ongoing monitoring and evaluation (M&E) to enable programs to adapt, improve, and generate evidence of impact to attract new partners and funding;Create a sustainability plan at the outset to ensure that program impact is maintained beyond the conclusion of initial funding;Embed programs into local health systems to ensure that investments leverage existing infrastructure, relationships, and resources, and that impact can be sustained beyond the life of the program;Employ locally-adapted curricula and appropriate teaching techniques to maximize transfer and retention of relevant knowledge;Incorporate supportive supervision into programs to ensure that transferred knowledge is maintained and acted upon;Facilitate and support regular convening and communication, enabling continuous learning for improvement.In addition to describing the approach taken by MVN-A and the results achieved in the four focus countries, this paper provides additional detail on each lesson, supported by case studies from the MVNA experience

Sustainable financing for new vaccines in Indonesia: challenges and strategies

Immunization is one of the most cost-effective interventions in global health and has a crucial role in achieving 14 of the 17 sustainable development goals (SDGs). The issue of sustainable financing for new vaccines is particularly pertinent as Indonesia transitions away from extensive Gavi support towards a self-financing immunization system. As the current immunization system transitions, practical solutions must be found and applied to provide more flexibility in the budget for financing immunizations without sacrificing the current healthcare system’s needs. Despite the fact that economic evaluation studies are essential as an initial step to ensure financial readiness, the lack of reliable data is the first barrier to Indonesia’s journey toward a self-financing immunization system. To overcome this problem, standardization of data collection strategies and methodologies are required. In particular, Indonesia may have to explore other options to increase revenue for its immunization system, such as through general revenue from the central government, a sector-wide approach to financing, and a national trust fund. To deal with the tight immunization budget and its consequences, Indonesia also has to restructure its immunization system, which can be implemented through province block grants, insurance mandate and subsidy. Taking the potential of a COVID-19 vaccine into account, the Indonesian government should consider a number of costs and issues beyond the development and procurement of vaccines. The costs of delivering vaccines to the remote parts of Indonesia, implementing the necessary infrastructure, and modifying vaccine delivery are also important in this time of transition. These constraints must be addressed in the new self-financing system and other public health efforts must be increased to decrease the burden of infectious disease as Indonesia develops a stronger immunization system

Strategies to revitalize immunization service provision in urban settings of Ethiopia

AbstractBackground: Improving routine immunization in the urban population is an essential element to address immunization coverage and equity. In rural areas, deliberate efforts are made to reach the populations using adapted strategies such as outreaches while specificities of urban populations are generally not considered in immunization programs of Ethiopia.Aim: To explore the barriers and alternative strategies for immunization service provision in urban settings of Ethiopia.Methods: A qualitative study with a phenomenological study design was conducted in selected cities of Addis Ababa, Dire Dawa and Mekele from June to August 2020. Data was collected at different levels of the health system and the community by using a piloted interview guide. Thirty-five key informants and nine in-depth interviews were conducted. Audio-records of interviews were transcribed verbatim, coded and thematic analysis was performed using Open code version 4.02. software.Results: Our finding revealed that the routine immunization service provision strategy in Addis Ababa, Dire Dawa and Mekele cities was a static approach. Service inaccessibility, poor defaulter tracking mechanisms, substandard service in private facilities, shortage of supplies, and lack of training were the main barriers. We explored alternative strategies to revitalize the Expanded Program on Immunization (EPI) including, expanding services to marginalized populations, outreach/home to home service provision, expanding services to private health facilities, and inter-facility linkage through digitalization.Conclusions: The existing immunization service provision strategies in urban settings are not adequate to reach all children. Immunization service inaccessibility and substandard services were the main barriers hindering service provision. Program managers should expand routine service access to marginalized populations through outreach services, by strengthening the public-private partnership, and integrating technological innovations (like digitalization of the EPI program and application of mHealth reminders) to facilitate inter-facility linkage. [Ethiop. J. Health Dev. 2021; 35(SI-3):98-110]Keywords: Immunization, Vaccination, Urban, Revitalize, Private Facility, Ethiopi

Measuring the health systems impact of disease control programmes: a critical reflection on the WHO building blocks framework.

BACKGROUND: The WHO health systems Building Blocks framework has become ubiquitous in health systems research. However, it was not developed as a research instrument, but rather to facilitate investments of resources in health systems. In this paper, we reflect on the advantages and limitations of using the framework in applied research, as experienced in three empirical vaccine studies we have undertaken. DISCUSSION: We argue that while the Building Blocks framework is valuable because of its simplicity and ability to provide a common language for researchers, it is not suitable for analysing dynamic, complex and inter-linked systems impacts. In our three studies, we found that the mechanical segmentation of effects by the WHO building blocks, without recognition of their interactions, hindered the understanding of impacts on systems as a whole. Other important limitations were the artificial equal weight given to each building block and the challenge in capturing longer term effects and opportunity costs. Another criticism is not of the framework per se, but rather how it is typically used, with a focus on the six building blocks to the neglect of the dynamic process and outcome aspects of health systems.We believe the framework would be improved by making three amendments: integrating the missing "demand" component; incorporating an overarching, holistic health systems viewpoint and including scope for interactions between components. If researchers choose to use the Building Blocks framework, we recommend that it be adapted to the specific study question and context, with formative research and piloting conducted in order to inform this adaptation. SUMMARY: As with frameworks in general, the WHO Building Blocks framework is valuable because it creates a common language and shared understanding. However, for applied research, it falls short of what is needed to holistically evaluate the impact of specific interventions on health systems. We propose that if researchers use the framework, it should be adapted and made context-specific

Health systems constraints and facilitators of national immunization programs in low- and middle- income countries

Like most health interventions, National Immunization Programs (NIPs) are embedded within health systems. This means that NIPs and health systems exist in a constant interaction. Vaccine preventable diseases are widely recognized as the chief cause of morbidity, disability and mortality worldwide and NIPs are understood to be one of the most cost-effective interventions against this burden. In low and middle- income countries (LMICs), where the burden of disease is high, NIPs have been reported to perform at suboptimal levels. It has been suggested that this suboptimal performance of NIPs can be associated with the poor state of health systems in LMIC. Despite this, the interaction between NIPs and health systems is poorly understood. In addition to this, systematic evidence on how health systems constraints and facilitators impact on the performance of NIPs in LMICs is scarce. To address this evidence gap, a systematic review study was conducted, that involved an initial scoping review of the evidence-base on NIPs and health systems in LMICs from which a logic model was developed. This logic model was then applied as a guide for a qualitative systematic review aimed at assessing the health systems constraints and facilitators of NIP performance in sub-Saharan Africa. The findings of this review suggest that well-performing NIPs are those that operate within enabling health systems, characterized by the availability of strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist and include the limited capacity of health workers in sub-Saharan Africa, weak country infrastructure, poor service delivery, inadequate vaccine communication and ineffective community engagement in immunization programs. This systematic review study contributes to our limited understanding of the interaction between NIPs and health systems. In addition, the findings show how system-wide constraints and facilitators impact on the performance of NIPs. These findings have relevance for ongoing health systems strengthening initiatives, especially where NIPs are concerned

2013 Annual Letter from Bill Gates

In previous annual letters, Gates focused on the power of innovation to reduce hunger, poverty, and disease. But any innovation -- whether it's a new vaccine or an improved seed -- can't have an impact unless it reaches the people who will benefit from it. That's why in this year's letter, Gates discusses how innovations in measurement are critical to finding new, effective ways to deliver these tools and services to the clinics, family farms, and classrooms that need them.The Foundation is supporting these efforts, but more needs to be done. Given how tight budgets are around the world, governments are rightfully demanding effectiveness in the programs they pay for. To address these demands, we need better measurement tools to determine which approaches work and which do not. In this letter, Gates highlights strong examples from the past year of how measurement is making a difference. In Colorado, Melinda and Bill learned how a school district is pioneering a new system to measure and promote teacher effectiveness. In Ethiopia, Gates witnessed how a poor country, pursuing goals set by the United Nations, delivered better health services to its people. In Nigeria, the digital revolution has allowed the foundation to improve the use of measurement in the campaign to eradicate polio. Thanks to cell phones, satellites, and cheap sensors, data can be gathered and organized with increasing speed and accuracy

EVALUATION OF THE VACCINE COVERAGE FOR CHILDREN UNDER 5-YEARS-OLD IN HOUAPHAN PROVINCE, LAO PDR

Background: Immunization plays a vital role in the lives of children by protecting them against infectious diseases. such as Measles, Polio, Tuberculosis, Hepatitis B, Diphtheria, whopping cough, Tetanus etc. There are different programmes and facilities for newborn and child health under National Health Mission (NHM). However, despite these schemes and programmes, the immunization coverage rate in rural area of Lao PDR are quite low compared to urban. In this Study, we present a critical review of the various factors, schemes and research currently being undergoing in child immunization. Methods: We analyzed second-hand data were provided by the Directorate General of Health Prevention of Ministry of Health Lao PDR in 2018 childhood immunization coverage record by different vaccine, target population background characteristic, In particular, in order to preliminarily find the factors of the immunization coverage failure in rural area, Email, Group conference through what’s app Video call in-depth, semi-structured interviews were undertaken with government officials, provincial government official, healthcare workers (HCWs) , Midwife and mother. Results: The results of this study, the percentage of fully immunized children coverage in rural area increased slowly1% only from 55% in 2018 to 56% in 2019. But in urban area has increased significantly 22% from 71% in 2018 to 93% in 2019 due to the EPI Department in urban area has improved its performance at health centers and ensure that vaccines are available with proper storage and maintenance of cold chain. This high coverage in urban could be due to better health service and distance from the health center as compared to rural area, results for interview vaccine related resource supply, community participant’s knowledge about vaccination, distance from health care center factors affecting the lower community demand for immunization in rural area. Conclusion: While impressive gains have been made in reducing infant mortality and increasing immunization coverage in Lao PDR, persistent inequalities remain in rural area. International organization (WHO) and government of Lao PDR each have important roles in supporting not only vaccine purchase, but also infrastructure efforts and supervision that can achieve and sustain national immunization goals. Immunization policy needs to be national in scope. At the same time, must be flexible enough to respond to special circumstances that occur at urban and remote area.open석

Implementation fidelity and challenges of optimal cold chain management in Assossa district health system, Benshangul-Gumuz region, Western Ethiopia

AbstractIntroduction: Preventive programs which have proven to be effective in clinical trials may not necessarily impact the health and wellbeing of the community unless they are implemented with fidelity. While cold chain is the backbone of immunization programs, limited studies exist to explain fidelity implementation which likely contributes to a lack of evidence-based instructional practices of cold chain management.Aim: This study aimed to explore the fidelity implementation and challenges of optimal cold chain management in the Benshangul-gumuz region.Methods: A qualitative approach was utilized to explore the underlying challenges to optimum implementation of cold chain management in Benshangul-gumuz region. Observational techniques and key informant interviews with 12 key-informants were conducted. Data was collected at all levels of the health system including, the regional health bureau, Ethiopian Pharmaceuticals Supply Agency hub, district health offices, Health centers, and health posts. Data analysis and interpretation was performed using the framework analysis approach. Open Code 4.02 software was used for analysis.Findings: This study identified three main themes including adherence to intervention, human resource development, and availability and use of resources. The findings also revealed that a significant number of the employees were not adhering to the optimal cold chain management guidelines. Staff development, availability and utilization of equipment and related finances were major fidelity implementation challenges of cold chain management.Conclusions: Across the health facilities under study, implementation fidelity of cold chain management was considered poor. Human resource development, proper allocation and effective management of logistics and related finance could facilitate optimal cold chain management practices, and efforts to save lives through delivery of safe and quality vaccines. [Ethiop. J. Health Dev. 2021; 35(SI-3):03-08]Keywords: Cold chain management, Implementation fidelity, Challenges, Ethiopi