Exemplars in vaccine delivery protocol: a case-study-based identification and evaluation of critical factors in achieving high and sustained childhood immunisation coverage in selected low-income and lower-middle-income countries

Drivers of success in global health outcomes: A content analysis of Exemplar studies

Applying a positive outlier lens is one effective approach for generating evidence to inform global health policy, program, and funding decisions. Exemplars in Global Health (EGH) is a program that studies positive outlier countries that have made extraordinary progress in health outcomes (despite limited resources) and disseminates their successes through multiple types of outputs. To date, EGH has studied, or is studying, 14 global health topics in 28 countries. This paper aims to identify findings, summarized as themes and sub-themes, that appear among all completed EGH studies. We developed a conceptual framework and used a content analysis approach to identify the top thematic areas that appear as drivers for programmatic success across EGH studies that were completed between June 2020-May 2023. The EGH studies (N = 31) spanned six topics including under-five child mortality (n = 6), childhood stunting (n = 5), community health workers (CHW) (n = 4), vaccine delivery (n = 3), COVID-19 response (n = 6), and newborn and maternal mortality reduction (n = 7) across 19 countries in sub-Saharan Africa, Latin America, South and Central Asia, and the Caribbean regions. Top drivers of success were defined as those critical or catalytic in achieving the intended outcome. Eight key drivers were identified: (1) efficient data collection and use for decision-making, (2) strong political commitment and health leadership, (3) effective stakeholder coordination, (4) a local, connected, and capacitated workforce, (5) intentional women's empowerment and engagement, (6) effective adoption and implementation of national policies, (7) effective and sustainable financing, and (8) equitable, efficient outreach and targeting. These cross-cutting drivers span a broad range of development outcomes, sectors, and populations, and indicate a need to effectively integrate people, systems, and sectors to improve global health outcomes. Findings from this study aim to support peer learning among countries and support evidence-based decision-making for funders, policymakers, and other key stakeholders.

Critical success factors for high routine immunisation performance: a qualitative analysis of interviews and focus groups from Nepal, Senegal, and Zambia

OBJECTIVES

Vaccination averts an estimated 2-3 million deaths annually. Although vaccine coverage improvements across Africa and South Asia have remained below global targets, several countries have outperformed their peers with significant increases in coverage. The objective of this study was to examine these countries' vaccination programmes and to identify and describe critical success factors that may have supported these improvements.

DESIGN

Multiple case study design using qualitative research methods.

SETTING

Three countries with high routine immunisation rates: Nepal, Senegal, and Zambia.

PARTICIPANTS

We conducted 207 key informant interviews and 71 focus group discussions with a total of 678 participants. Participants were recruited from all levels, including government officials, health facility staff, frontline workers, community health workers, and parents. Participants were recruited from both urban and rural districts in Nepal, Senegal, and Zambia.

RESULTS

Our data revealed that the critical success factors for vaccination programmes relied on the cultural, historical, and statutory context in which the interventions were delivered. In Nepal, Senegal, and Zambia, high immunisation coverage was driven by (1) strong governance structures and healthy policy environments; (2) adjacent successes in health system strengthening; (3) government-led community engagement initiatives, and (4) adaptation considering contextual factors at all levels of the health system.

CONCLUSIONS

Throughout this project, our analysis returned to the importance of defining and understanding the context, governance, financing, and health systems within a country, rather than focusing on any one intervention. This paper augments findings from existing literature by highlighting how contextual factors impact implementation decisions that have led to improvements in childhood vaccine delivery. Findings from this research may help identify transferable lessons and support actionable recommendations to improve national immunisation coverage in other settings.

Factors associated with vaccine coverage improvements in Senegal between 2005 and 2019: a quantitative retrospective analysis

OBJECTIVE

Senegal has demonstrated catalytic improvements in national coverage rates for early childhood vaccination, despite lower development assistance for childhood vaccines in Senegal compared with other low-income and lower-middle income countries. Understanding factors associated with historical changes in childhood vaccine coverage in Senegal, as well as heterogeneities across its 14 regions, can highlight effective practices that might be adapted to improve vaccine coverage elsewhere.

DESIGN

Childhood vaccination coverage rates, demographic information and health system characteristics were identified from Senegal's Demographic and Health Surveys (DHS) and Senegal national reports for years 2005-2019. Multivariate logistic and linear regression analyses were performed to determine statistical associations of demographic and health system characteristics with respect to childhood vaccination coverage rates.

SETTING

The 14 administrative regions of Senegal were chosen for analysis.

PARTICIPANTS

DHS women's survey respondents with living children aged 12-23 months for survey years 2005-2019.

OUTCOME MEASURES

Immunisation with the third dose of the diphtheria-tetanus-pertussis vaccine (DTP3), widely used as a proxy for estimating immunisation coverage levels and the retention of children in the vaccine programme.

RESULTS

Factors associated with childhood vaccination coverage include urban residence (β=0.61, p=0.0157), female literacy (β=1.11, p=0.0007), skilled prenatal care (β=1.80, p<0.0001) and self-reported ease of access to care when sick, considering travel distance to a healthcare facility (β=-0.70, p=0.0009) and concerns over travelling alone (β=-1.08, p<0.0001). Higher coverage with less variability over time was reported in urban areas near the capital and the coast (p=0.076), with increased coverage in recent years in more rural and landlocked areas.

CONCLUSIONS

Childhood vaccination was more likely among children whose mothers had higher literacy, received skilled prenatal care and had perceived ease of access to care when sick. Overall, vaccination coverage is high in Senegal and disparities in coverage between regions have decreased significantly in recent years.

Drivers of early childhood vaccination success in Nepal, Senegal, and Zambia: a multiple case study analysis using the Consolidated Framework for Implementation Research

INTRODUCTION

The fundamental components of a vaccine delivery system are well-documented, but robust evidence is needed on how the related processes and implementation strategies - including the facilitators and barriers - contribute to improvements in childhood vaccination coverage. The purpose of this study was to identify critical facilitators and barriers to the implementation of common interventions across three countries that have dramatically increased coverage of early childhood vaccination over the past 20 years, and to qualify common or divergent themes in their success.

METHODS

We conducted 278 key informant interviews and focus group discussions with public health leaders at the regional, district, and local levels and community members in Nepal, Senegal, and Zambia to identify intervention activities and the facilitators and barriers to implementation. We used thematic analysis grounded in the Consolidated Framework for Implementation Research (CFIR) constructs of inner and outer settings to identify immunization program key facilitators and barriers.

RESULTS

We found that the common facilitators to program implementation across the countries were the CFIR inner setting constructs of (1) networks and communications, (2) goals and feedback, (3) relative priority, and (4) readiness for implementation and outer setting constructs of (5) cosmopolitanism and (6) external policies and mandates. The common barriers were incentives and rewards, available resources, access to knowledge and information, and patients' needs and resources. Critical to the success of these national immunization programs were prioritization and codification of health as a human right, clear chain of command and shared ownership of immunization, communication of program goals and feedback, offering of incentives at multiple levels, training of staff central to vaccination education, the provision of resources to support the program, key partnerships and guidance on implementation and adoption of vaccination policies.

CONCLUSION

Adequate organizational commitment, resources, communication, training, and partnerships were the most critical facilitators for these countries to improve childhood vaccination.

Critical interventions for demand generation in Zambia, Nepal, and Senegal with regards to the 5C psychological antecedents of vaccination

Introduction

Childhood vaccination is an effective intervention for lowering the burden of infectious disease. Vaccine coverage has increased globally, but vaccine hesitancy and refusal threatens these gains. The 5C psychological antecedents of vaccination ("5C") provides a validated measure of "vaccine hesitancy or confidence" to assess individual thoughts and behaviors behind vaccination. We investigated population-level factors that contributed to high and sustained vaccination coverage in Zambia, Nepal, and Senegal, and alignment with the 5Cs.

Methods

Data was collected in the larger Exemplars in Vaccine Delivery study, from focus group discussions (FDGs) and key informant interviews (KIIs) at the national, regional, district, health facility, and community levels of health systems in Zambia, Nepal, and Senegal. We assessed the demand environment, as relayed by participants, and identified interventions reported as successful for demand generation, then retroactively aligned the interventions with the 5C constructs.

Results

Demand was positively correlated with high confidence and collective responsibility. Psychological constraints sometimes impacted demand. Physical constraints created barriers in some communities, particularly difficult to access (i.e., mountainous). Occasionally, physical constraints did not affect vaccination behavior - parents believed the benefits of vaccination worth pursuing. Factors negatively correlated with demand and intent, complacency and calculation, had limited impact. Critical interventions were: targeted and tailored health education activities (media partnerships, school outreach); community engagement; community ownership; and community involvement (community health workers, leaders, religious figures).

Conclusion

We found similar interventions used to generate demand, with strategies aligned with the 5C constructs. Categorizing interventions by drivers of demand may help strategic planning and the division of resources; decision makers may choose to implement our suggested interventions. Assessing the 5Cs allows decision-makers to operationalize demand generation into concrete interventions and policies, and determine the individual impact of these constructs on the population and focus efforts on interventions tailored to a specific need.

Addressing Immunization Inequity—What Have the International Community and India Learned over 35 Years?

Countries around the world established immunization programs over 40 years ago to reach all infants. The maturity of these preventive health programs offers some useful learning on the importance of, and components needed for, population-based services to reach all communities. A public health success, ensuring equity in immunization, requires a multi-faceted approach that includes sustained government and partner commitment and human, financial, and program operational resources. Evidence from India’s Universal Immunization Program (UIP) across stabilizing vaccine supply and services, enhancing access, and generating demand for vaccines in the community provides a useful case study. The political leadership in India took advantage of the two decades of learning from polio eradication and focused initiatives, such as the National Health Mission and Intensified Mission Indradhanush, to reach populations with immunization services. With a goal of leaving no one behind, India’s UIP and partners are bringing essential rotavirus and pneumococcal vaccines nationwide, upgrading vaccine cold chain and supply systems with technologies, such as the electronic Vaccine Intelligence Network (eVIN), and optimizing funding for local needs through the Program Implementation Plan (PIP) budgetary processes and building health worker capacities through training, awareness, and e-learning.

Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children

Background: Understanding past successes in reaching unvaccinated or “zero-dose” children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. Methods: Focusing on 2000–2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria–tetanus–pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential ‘exemplars’, demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called “neighborhood analyses” were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. Results: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions—national prevalence and subnational gaps—while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. Conclusions: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children—especially across variable contexts and different drivers of inequality—could support faster, sustainable advances toward greater vaccination equity worldwide.

Critical success factors for routine immunization performance: A case study of Zambia 2000 to 2018

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This paper describes how policies and programs contributed to improved vaccine coverage in Zambia.

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Communication, coordination, and collaboration between implementing levels were imperative.

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Adjacent successes in health systems strengthening and governance were leveraged.

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Policies in Zambia include flexibility in implementation for tailored approaches in each district.

Introduction

The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies prove effective at driving coverage is not well-established. To address this gap, we identified critical success factors associated with advancing key policies and programs that may have led to the substantial changes in routine childhood immunization coverage in Zambia between 2000 and 2018.

Methods

We identified Zambia as an exemplar in the delivery of childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national and subnational levels, we investigated factors that contributed to high and sustained vaccination coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data.

Results

The following success factors emerged: 1) the Inter-agency Coordinating Committee was strengthened for long-term engagement which, complemented by the Zambia Immunization Technical Advisory Group, is valued by the government and integrated into national-level decision-making; 2) the Ministry of Health improved the coordination of data collection and review for informed decision-making across all levels; 3) Regional multi-actor committees identified development priorities, strategies, and funding, and iteratively adjusted policies to account for facilitators, barriers, and lessons learned; 4) Vaccine messaging was disseminated through multiple channels, including the media and community leaders, increasing trust in the government by community members; 5) The Zambia Ministry of Health and Churches Health Association of Zambia formalized a long-term organizational relationship to leverage the strengths of faith-based organizations; and 6) Neighborhood Health Committees spearheaded community-driven strategies via community action planning and ultimately strengthened the link between communities and health facilities.

Conclusion

Broader health systems strengthening and strong partnerships between various levels of the government, communities, and external organizations were critical factors that accelerated vaccine coverage in Zambia. These partnerships were leveraged to strengthen the overall health system and healthcare governance.