Impact and effect mechanisms of mass campaigns in resource-constrained health systems: quasi-experimental evidence from polio eradication in Nigeria

Abstract

BackgroundMass campaigns are a key strategy for delivering life-saving interventions under Global Health Initiatives, especially in weak health system contexts. They are frequently designed parallel to the health system to rapidly achieve programme targets such as vaccination coverage, but we lack quantitative evidence demonstrating their impact and effect mechanisms on health system performance at sub-/national level. This longitudinal study responds to this gap through an analysis of polio eradication campaigns in Nigeria.MethodsUsing four rounds of Demographic and Health Surveys in Nigeria between October 2000 and December 2017, we created a longitudinal dataset containing 88 881 under-5 children/pregnancies. We estimated the relationships between individuals’ campaign exposure and health system performance indices (full RI schedule attainment, maternal healthcare services utilisation and child survival) using multilevel, mixed-effects regression models applied nationally and stratified by the six geopolitical zones in Nigeria.ResultsNationally, high-frequency mass campaigns had detrimental health systems effects that potentially left 3.6 million children deprived of full immunisation. The frequency of campaigns was most concentrated in regions with weak health systems, where the operations of RI were disrupted, alongside negative effects on child survival and institutional delivery. In contrast, regions with relatively strong health systems and few campaigns experienced beneficial effects on maternal healthcare service utilisation.ConclusionsAs we provide evidence that well-functioning health systems can benefit from mass campaigns under Global Health Initiatives, our work also challenges the established wisdom to intensify mass campaigns in weaker health systems to bypass service provision bottlenecks. Mass campaigns do not inherently benefit or damage a health system, but frequent campaigns in weak health system contexts can impede service provision. We call for an additional burden of proof and active efforts to integrate mass campaigns into routine health services by harmonising implementation plans and service delivery in weak health system contexts.

Zero- or missed-dose children in Nigeria: Contributing factors and interventions to overcome immunization service delivery challenges

“… Factor Frequency Note Reference Individual factors Maternal factors Maternal literacy and education 22 High maternal education consistently associated with higher vaccination rates, although one national study found that education level was not significant when adjusted for literacy [32] . [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] Maternal care (health facility birth) 12 Giving birth in a health facility was significantly associated with vaccination, particularly for birth doses. However, delivery on weekends or outside routine vaccination days, and prematurity or low birth weight, were reasons for delayed or missed birth dose vaccinations [54] .…”

“… [48] , [56] Socioeconomic factors Socioeconomic status 16 Vaccination rates consistently increased as household wealth increased. [7] , [32] , [35] , [37] , [38] , [39] , [44] , [45] , [48] , [50] , [51] , [53] , [55] , [59] , [66] , [67] Paternal / caregiver factors Paternal / caregiver support for vaccination 8 Higher paternal or parental / caregiver education, employment, awareness, and support for vaccination was also associated with higher childhood vaccination coverage. [45] , [51] , [52] , [56] , [68] , [69] , [70] , [71] , [72] Paternal permission for vaccination 6 Coverage was lower where caregivers, particularly fathers, refused permission for vaccination.…”

“… [80] , [82] , [97] , [113] , [117] , [118] , [120] , [125] Using supplementary vaccination campaigns 5 Using supplementary vaccination campaigns (including fixed and temporary posts in strategic areas, and ‘in-between’ round campaigns successfully increased ‘last-mile’ coverage (n = 4) while one study was critical. [112] , [113] , [131] , [133] , [134] Using GIS and satellite data 4 Using GIS and satellite data to inform microplanning and team assignments improved identification and coverage of target areas vs hand-drawn maps. [91] , [113] , [129] , [135] Using real-time performance data 4 Using real-time performance data improved coverage of vaccination campaigns (e.g., leveraging existing polio reporting structures; analyzing and report daily campaign data; providing feedback).…”

A qualitative exploration of the contributions of Polio Eradication Initiative to the Nigerian health system: policy implications for polio transition planning

“…These other maternal and child health programs differ from the polio program in terms of the collaborative efforts involved in the program when compared to other programs [ 3 , 38 ]. So, they face challenges in lack of extensive funding mechanism, support from the traditional, religious, and political leaders and donors, and monetary incentives for health workers' participation.…”

Multi-country review of ITN routine distribution data: are ANC and EPI channels achieving their potential?

“…A recent paper by Haenssgen et al [ 24 ] provides evidence that well-functioning health systems can benefit from mass campaigns but challenges the established wisdom to intensify mass campaigns in weaker health systems to bypass service provision bottlenecks. They point out that mass campaigns do not inherently benefit or damage a health system, but frequent campaigns in weak health system contexts can impede service provision, and they call for an additional burden of proof and active efforts to integrate the services delivered through mass campaigns into routine health services by harmonizing implementation plans and service delivery in weak health system contexts.…”