Strengthening routine immunization services and sustainable financing for immunization

Country Activities

IMMUNIZATIONbasics has activities in the following countries:

Africa

Democratic Republic of Congo (DRC)

Country Situation
DRC is a large, diverse country that has endured political instability and war for much of the last decade. Given the country's weak transportation and communication systems and its security situation, the national immunization program has made remarkable strides in improving routine immunization coverage. Although much work remains to be done before reaching consistently satisfactory performance, progress in recent years has been encouraging.

A semiannual EPI review in June 2005 found that routine immunization coverage in most provinces had improved compared with the same period in 2004, that the completeness of reporting was good for most provinces, and that DPT1-DPT3 drop-out rates had declined. The Reaching Every Zone (REZ) approach (DRC's version of Reaching Every District) continues to be implemented in the 161 health zones where it was introduced in 2004, and coverage of all antigens has increased in these zones. In 2005, the number of zones implementing REZ should expand from 161 to 339, increasing REZ coverage from 45% to approximately 70% of the country's total population. Vaccine management remains a challenge, with periodic short-term stock-outs for various antigens reported at the zonal level. In 2005, planning for multi-antigen campaigns is under way and measles surveillance efforts have increased in preparation for sub-national measles campaigns. Focused polio immunization campaigns are also being conducted along DRC's borders to prevent the reintroduction of wild polio virus from surrounding countries.

How IMMUNIZATIONbasics Is Helping
IMMUNIZATIONbasics continued the technical support provided to the DRC by the BASICS project. From 1996-2004, BASICS I and II worked with the Ministry of Health to restructure the national EPI, develop the national immunization Inter-Agency Coordinating Committee (ICC), strengthen routine immunization systems, improve the collection and use of data at all levels, and support national polio eradication and measles control efforts.

IMMUNIZATIONbasics continued as an active technical advisor on immunization in DRC, working closely with the national EPI and ICC to improve immunization service delivery, increase demand, improve coverage, and track key immunization indicators. Through the on-going work of a small national team and periodic visits from headquarters, the project's work was directed toward:

• Assisting the national EPI in meeting its GAVI requirements, including the completion of a national Financial Sustainability Plan and preparations for an external Data Quality Audit;
• Helping to introduce, strengthen and document the experiences of provincial ICCs;
• Providing technical assistance to the EPI and its partners (e.g. CRS, UNICEF, WHO, SANRU and Rotary) toward the implementation, monitoring, and documentation of the "Reaching Every Zone" approach, including providing feedback and facilitating planning at zonal, antenna, provincial, and national levels;
• Working with health zones to improve communication and community links with health services, as well as the use of data and micro-planning at local levels to strengthen local services and improve coverage;
• Providing technical support to improve data quality and use at all levels;
• Supporting capacity building and training on EPI in selected zones and provinces, including co-facilitating mid-level EPI manager's training courses for provincial, antenna and zonal staff on a cascade basis;
• Providing support to polio eradication and measles control initiatives with a focus on routine immunization strengthening as part of these efforts; and,
• Participating in and helping to plan semi-annual EPI reviews and annual planning meetings hosted by the national EPI and attended by its ICC partners.

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Nigeria

Country Situation
With a population of approximately 140 million, Nigeria remains Africa’s most populous nation. Vaccine preventable diseases account for approximately 22% of child deaths in the country; amounting to over 200,000 deaths per year. The Expanded Program on Immunization (EPI), responsible for routinely delivering immunization, started in the late 1970s. In 1990, reported DPT3 coverage in infants (<12 months of age) reached an estimated 56%. During the years following the global Universal Childhood Immunization efforts that culminated in 1990, immunization coverage rates in Nigeria declined significantly. Preliminary results of a 2006 national coverage survey reported 36% DPT3 coverage and only 18% of children fully immunized (aged 12-23 months at survey time, using card + recall). The survey results reveal significant differences across zones ranging from 0%-40% fully immunized children.

The Government of Nigeria has recently accelerated efforts to revive immunization services. EPI officials developed a blue print with a multi-year plan including activities for improving routine immunization coverage. They adapted the global Reaching Every District strategy into a Reaching Every Ward approach which is in the process of being phased in across the 37 states. Additionally in April 2006, the National Program on Immunization developed an approach of integrating other antigens and child survival interventions with the polio eradication campaigns.

Numerous partner agencies are implementing projects in tandem with the Government of Nigeria aiming to strengthen routine immunization in the country, particularly across the northern states. These include USAID’s Community Participation for Action in the Social Sector Project (COMPASS), World Health Organization, United Nations Children’s Fund, EU Prime, UK Department for International Development’s (DFID) Partnership for Transforming Health Systems and also DFID’s new project, Promoting the Revitalization of Routine Immunization in Northern Nigeria.

How IMMUNIZATIONbasics Is Helping
IMMUNIZATIONbasics technically supported the USAID Mission and collaborated with organizations engaged in routine immunization at the national and state levels—including the National Primary Health Care Development Agency (NPHCDA), State Ministries of Health, Ministries of Local Government/Departments of Local Government Affairs and international partners. IMMUNIZATIONbasics worked in the two northern states of Bauchi and Sokoto with a combined population of 8.5 million.

Project implementation in both states began in 2007, with an approach to provide support in strengthening the routine immunization system over the course of the following two and a half years in all 43 local government areas, or LGAs (20 Bauchi, 23 Sokoto). A phasing in strategy was employed in order to integrate lessons learned as the project progressed.

Specific areas the project targets included:

• Promoting regular distribution of vaccine and vaccination supplies to service delivery points;
• Improving data quality and use at LGA and health facility levels;
• Increasing and sustaining optimal attendance during immunization sessions;
• Increasing service delivery points providing routine immunizations.

To achieve these objectives, IMMUNIZATIONbasics worked directly with immunization program managers at the State Ministry of Health and Ministry of Local Government/Department of Local Government Affairs. IMMUNIZATIONbasics LGA staff worked directly with immunization staff at the LGA and health facility levels, with using existing resources and systems to complement the efforts of NPHCDA and partners. IMMUNIZATIONbasics also provided technical support to the USAID Mission and other partners on immunization and disease control issues and initiatives of global, inter-country and nationwide importance.

Immunization resources from and for Nigeria

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Rwanda

Country Situation
Rwanda has one of the strongest immunization programs in Africa. The country's commitment to protecting its children from vaccine-preventable diseases has resulted in DTP3 coverage in excess of 80% for eight of the past ten years. The country has eliminated maternal and neonatal tetanus and successfully introduced hepatitis B and Haemophilus influenzae type b vaccines in the form of a combined, pentavalent vaccine.

However, an analysis in 2004 indicated that only 11 of the country's 39 districts (28%) were able to sustain >80% DTP3 coverage in each of the preceding three years, indicating instability of coverage. Like other MCH services, the immunization program also faced the possibility of reduced attention due to the predominant focus on HIV/AIDS and limited human resources at all levels of the health system.

There were also funding concerns. The introduction of pentavalent vaccine was achieved through a five-year donation of this vaccine from the Global Alliance for Vaccines and Immunization (GAVI). In 2001, prior to the introduction of the pentavalent vaccine, the national immunization program cost approximately $2 million per year; in 2006 it was expected that the cost woud exceed $7 million. Future financing from GAVI will depend on co-financing from the government and its partners, so the government must take steps to increase the financial sustainability of its program if it is to maintain the new vaccines.

How IMMUNIZATIONbasics Is Helping
USAID/Kigali requested that IMMUNIZATIONbasics assist the national immunization program in planning for the financial sustainability of its program by building skills in costing, financing and advocacy. IMMUNIZATIONbasics provided short-term technical support to the Ministry of Health in updating its costing projections for immunization, estimating financial gaps, and developing financial strategies to maintain reliable financing for its immunization program in the future.

The high level of immunization program performance stands in sharp contrast with other health indicators, especially those for maternal and child health. In light of this, IMMUNIZATIONbasics provided short-term technical assistance to the MOH and local partners to explore how the five immunization contacts in a child's first year of life can be better exploited to provide multiple services. Finally, IMMUNIZATIONbasics worked with the MOH and other partners to assure consistently strong program management at all levels.

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Asia

East Timor

Country Situation
A country of slightly fewer than one million people, East Timor (Timor-Leste) became an independent nation in 2002. It is still recovering from the widespread destruction of schools and health facilities and the migration of health and other professionals during years of war. Population-based coverage surveys in 2004 indicated that only about 15% of children 12-23 months of age had received three card-confirmed doses of DPT or one dose of measles vaccination. This figure rises to about 55% when recall based on the caregiver's memory is included. Timely coverage by 12 months of age is even lower. Children born during the previous 12 months to mothers with two or more TT vaccinations ranged from 13% (by card) to 60% (card plus recall). There is a high percentage of children with no immunizations and generally poor utilization of health facilities, even for curative care. The government must confront multiple serious health needs, including very high rates of malaria, dengue fever, tuberculosis, malnutrition, maternal mortality, and fertility.

How IMMUNIZATIONbasics Is Helping
IMMUNIZATIONbasics and the BASICS project collaborated in East Timor to establish Timor-Leste Asisténsia Integradu Saúde (TAIS), or the East Timor Integrated Maternal and Child Health Care Project. Field implementation began in mid-2005. The project provided technical support to the Ministry of Health to extend effective, proven newborn and child health interventions throughout the entire country. Core interventions included malaria prevention and treatment, nutrition and micronutrient care, pneumonia prevention and treatment, diarrhea prevention and treatment, essential newborn care, and immunization for vaccine-preventable childhood diseases.

TAIS built capacity at all levels in the Ministry of Health, focusing primarily on improving services at the district, sub-district and community levels. TAIS assisted the MOH and NGO partners to strengthen essential preventive services, such as immunization and malaria prevention and the case management of common childhood illnesses in households, communities and health facilities. In each district and sub-district, TAIS worked with elected and community leaders to use local health data for improved local planning and implementation of health services. This included giving feedback to communities to help motivate people's participation in health programs and movement towards more health-promoting behaviors. IMMUNIZATIONbasics focused on improving immunization policies, strategies and capabilities at the national and district levels--particularly service delivery and utilization within the districts.

TAIS worked with the MOH to:

• Deliver a package of proven child health interventions (immunization, vitamin A, insecticide-treated bed nets, timely treatment of malaria and pneumonia, etc.) through the formal health delivery system and in communities;
• Improve the technical effectiveness, efficiency, coverage and quality of preventive services and the management of childhood illnesses by community health workers and primary health care facilities (posts, centers);
• Increase community involvement and demand for preventive and curative services;
• Emphasize adoption of health-promoting behaviors within families;
• Strengthen the management and support systems required for effective delivery and sustainability of the package of child health interventions; and
• Leverage internal and external resources to sustain improvement in health status.

TAIS established a national and several district teams, all of which were supplemented by short-term technical assistance visits from IMMUNIZATIONbasics and BASICS.

Immunization resources from and for East Timor

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India

Credit: Vijay

Country Situation
Since 2003, the routine immunization program has received renewed attention from the Ministry of Health and Family Welfare (MOHFW) and its partners. The Ministry has prepared policy guidelines and a multi-year plan, conducted an immunization review in six poor-performing states, adapted the global Reaching Every District (RED) strategy, and created routine immunization cells at the national level and in four low-performing northern states. For the first time in more than a decade, it may be possible to reverse declining immunization coverage, which is currently less than 30% in several of the northern states.

How IMMUNIZATIONbasics Is Helping
IMMUNIZATIONbasics supported the USAID Mission and USAID-funded organizations engaged in routine immunization—including CARE's Integrated Nutrition and Health Project (INHP II), the Urban Health Resource Center (UHRC), and WHO's routine immunization cells at the national level and in several states. The project also provided support to the Ministry of Health at national level.

IMMUNIZATIONbasics:

• Participated in the MOHFW review of the Bihar State immunization program as part of a six-state, multi-party review;
• Worked with the World Bank in Rajasthan to assess implementation of the Immunization Strengthening Project;
• Participated in a multi-agency review of the Social Mobilization Network and the potential for expanding its work beyond polio; and
• Contributed to the design of a new routine immunization monitoring system.

IMMUNIZATIONbasics promoted new ideas for coordination among various community-based entities and the health services. The project supported CARE and UHRC in sharing their experiences in improving linkages between peripheral health workers and the communities they served. IMMUNIZATIONbasics also participated in the further design, adaptation and introduction of the RED approach in India, including participatory problem identification and solving.

Based in Delhi, IMMUNIZATIONbasics' Country Representative worked closely with the routine immunization cells and the other partners mentioned above.

Immunization resources from and for India

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