Drivers of routine immunization coverage improvement in Africa: findings from district-level case studies

Abstract

There is limited understanding of why routine immunization (RI) coverage improves in some settings in Africa and not in others. Using a grounded theory approach, we conducted in-depth case studies to understand pathways to coverage improvement by comparing immunization programme experience in 12 districts in three countries (Ethiopia, Cameroon and Ghana). Drawing on positive deviance or assets model techniques we compared the experience of districts where diphtheria–tetanus–pertussis (DTP3)/pentavalent3 (Penta3) coverage improved with districts where DTP3/Penta3 coverage remained unchanged (or steady) over the same period, focusing on basic readiness to deliver immunization services and drivers of coverage improvement. The results informed a model for immunization coverage improvement that emphasizes the dynamics of immunization systems at district level. In all districts, whether improving or steady, we found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. We found that the differences in coverage trends were due to factors other than basic RI system capacity or service readiness. We identified six common drivers of RI coverage performance improvement—four direct drivers and two enabling drivers—that were present in well-performing districts and weaker or absent in steady coverage districts, and map the pathways from driver to improved supply, demand and coverage. Findings emphasize the critical role of implementation strategies and the need for locally skilled managers that are capable of tailoring strategies to specific settings and community needs. The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunization system performance.

Engaging communities for increasing immunisation coverage: what do we know?

“…Programmes that use these approaches should also generate evidence in tandem to help pilot, plan, deliver and learn more from their experience. Other recent studies in the field of immunisation corroborate these findings (Fields and Kanagat 2012;Jain et al 2015;LaFond et al 2014).…”

“…Direct involvement of communities can help immunisation programmes increase their coverage and reduce dropout rates (LaFond et al 2014;WHO 2014a). We use the World Health Organization (WHO) definition of community:…”

Complete Child Immunisation: A Cluster Analysis of Positive Deviant Regions in Ghana

“…A key conclusion is that locally anchored research that is sensitive to social context should be a priority, focused on the role of local variation in the implementation of more effective immunisation policy. How can immunisation efforts be better fitted to specific communities, how can local demand for vaccination be stimulated, how can innovative management practices improve coverage in hard-to-reach segments in the community, and how can paediatric public health succeed even in the face of unsettled and impoverished local social conditions and resource scarcity [35][36][37][38][39][40]?.…”

“…The many socio-demographic factors associated with immunisation coverage in recent research include ethnicity and religion [26], caregiver's education [27], household economic status [28,29], maternal health literacy [29], maternal decision latitude [30], use of maternal and child health facilities [27], participation in vaccination campaigns [31] and urban versus rural living [32]. Few studies investigate why coverage has improved in some settings and not others [33,34] or use positive deviance lens [35]. Substantial inter-regional variation in immunisation coverage within countries [36] gives rise to questions about what regional-level factors might account for immunisation coverage variation.…”

Attitudes of health care professionals towards Mutual Health Organizations: evidence from two regions in the Northwest Province of Cameroon

“…Although the potential of MHOs is seen to reduce barriers to health care, they are still confronted with many challenges, including, to name a few, internal managing difficulties, lack of efficacy in financing and low penetration rates in the target population (Donfouet et al 2011;North West Special Fund for Health and EPOS Health Management 2012). There is still a lack of comprehensive studies of the impacts of MHO's on health care utilization, health status, and morbidity rates of their members (Wietler 2010); however, in the last years there has been an increasing rate of studies that try to assess the impact and contribution of MHOs to health care system performance, financing or access to health care in developing countries (Chankova et al 2008;Noubiap et al 2013;Nyemeck 2007;Spaan et al 2012).…”