BackgroundDemand side barriers to vaccination among rural and hard-to-reach populations in Chad are not yet well understood. Although innovative approaches such as linking human and animal vaccination increase vaccination uptake among mobile pastoralist communities, vaccination coverage in these communities is still lower than for rural settled populations. We hypothesize that mobile pastoralists’ communities in Chad face specific demand side barriers to access vaccination services. Understanding the factors that caregivers in these communities consider, explicitly or implicitly, in order to decide whether or not to vaccinate a child, in addition to understanding the provider’s perspectives, are essential elements to tailor vaccination programmes towards increasing vaccination acceptance and uptake.MethodsWe conducted a qualitative study in a rural health district in southern Chad in April 2016 with 12 key informant in-depth interviews and four focus group discussions (FGDs) including 35 male and female participants. Participants in the study included caregivers, traditional chiefs, local and religious leaders from mobile pastoralist communities, and health officials and staff. We conducted a content analysis using a pre-defined set of categories for vaccine hesitancy covering issues on harmful effects of vaccination, mistrust with vaccination programmes/services, issues with the health system and other issues.ResultsThe groups of demand side barriers reported most frequently in focus group discussions were mistrust on the expanded programme on immunization (EPI) and polio vaccination outreach services (53%, n = 94), followed by health system issues (34%, n = 94), and concerns related to potential harm of vaccines (13%, n = 94). Concerns identified by caregivers, health professionals and community leaders followed a similar pattern with issues on programme mistrust being most frequently reported and issues with harm least frequently reported. None of the health professionals reported concerns about vaccinations being potentially harmful.ConclusionMobile pastoralist communities face specific demand side barriers to vaccination. Understanding these barriers is essential to reduce vaccine hesitancy and increase vaccination uptake. Local health systems must plan for the periodic presence of pastoralist communities in their zones of responsibility and create more mutual trust.

Background One Health approaches such as the Joint human and animal vaccination programmes (JHAVP) are shown to be feasible and to increase health care access to hard-to-reach communities such as mobile pastoralists. However, the financial sustainability and the integration into the public health systems at the district level of such programmes are still challenging. The main objective of the present study was to give insight to the feasibility and financial sustainability of JHAVP integrated as part of the public health system in Chad. Methods We conducted a mixed methods study using semi-structured key informant interviews, focus group discussions and budget impact analysis. Strengths, weaknesses, opportunities, and threats were analysed regarding the feasibility and sustainability of the implementation of JHAVP in Danamadji health district in Chad. Feasibility was further analysed using three dimensions: acceptability, implementation, and adaptation. Financial sustainability of JHAVP was analysed through budget impact analysis of implementation of the programme at district level. Results The acceptability of this approach was regularly assessed by immunization campaign teams through evaluation meetings which included pastoralists. The presence of authorities in the meetings and workshops of the programme had an incentive effect since they represent a mark of consideration these populations generally declared to be lacking. The coordination between the public health and veterinary services at central and decentralized level seemed to be a key element in the success of the implementation of the programme. Regarding financial sustainability, the total incremental budget impact was 27% slightly decreasing to 26% after five years, which accounts for up to one third of the total budget of the district health office. Also, given that most of the costs for each round are recurrent costs, efficiency gains from scale effects over time are limited. Conclusion Based on these findings, we conclude that for JHAVP to be routinely delivered at the district health level, a considerable increase in financial resources would be required. The district could benefit from joint immunization to maintain contact with mobile pastoralists to promote the use of available immunization services at district level.

BackgroundOne Health approaches such as the Joint human and animal vaccination programmes (JHAVP) are shown to be feasible and to increase health care access to hard-to-reach communities such as mobile pastoralists. However, the financial sustainability and the integration into the public health systems at the district level of such programmes are still challenging. The main objective of the present study was to give insight to the feasibility and financial sustainability of JHAVP integrated as part of the public health system in Chad.MethodsWe conducted a mixed methods study using semi-structured key informant interviews, focus group discussions and budget impact analysis. Strengths, weaknesses, opportunities, and threats were analysed regarding the feasibility and sustainability of the implementation of JHAVP in Danamadji health district in Chad. Feasibility was further analysed using three dimensions: acceptability, implementation, and adaptation. Financial sustainability of JHAVP was analysed through budget impact analysis of implementation of the programme at district level.ResultsThe acceptability of this approach was regularly assessed by immunization campaign teams through evaluation meetings which included pastoralists. The presence of authorities in the meetings and workshops of the programme had an incentive effect since they represent a mark of consideration these populations generally declared to be lacking. The coordination between the public health and veterinary services at central and decentralized level seemed to be a key element in the success of the implementation of the programme. Regarding financial sustainability, the total incremental budget impact was 27% slightly decreasing to 26% after five years, which accounts for up to one third of the total budget of the district health office. Also, given that most of the costs for each round are recurrent costs, efficiency gains from scale effects over time are limited.ConclusionBased on these findings, we conclude that for JHAVP to be routinely delivered at the district health level, a considerable increase in financial resources would be required. The district could benefit from joint immunization to maintain contact with mobile pastoralists to promote the use of available immunization services at district level.

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