Drivers of Routine Immunization Coverage Improvement in Africa: Findings from District-Level Case Studies

"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."

To understand what drives improvements in routine immunisation (RI) coverage throughout Africa, the John Snow Inc. (JSI)-managed ARISE (Africa Routine Immunization System Essentials) project used an assets-based approach - as opposed to the more familiar gap/barrier/bottleneck analysis - to investigate the experience of 12 districts located in 3 countries: Ethiopia, Cameroon, and Ghana.

Rather than focusing on reasons why coverage was low, researchers applied a "positive deviance" lens - meaning they explored cases with positive outcomes - and compared the experience of districts where coverage improved with districts where coverage remained unchanged. They then delved into the dynamics of implementation and the interplay among drivers of change. Using this approach, they 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 immunisation services and drivers of coverage improvement. In all districts, whether improving or steady, they found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. The differences in coverage trends were due to factors other than basic RI system capacity or service readiness.

Six drivers of RI performance improvement emerged as common to the study districts where coverage improved. Although the way in which these drivers contributed to improved coverage varied by district, each was present in some way in the better-performing districts and was either absent or weaker in the study districts where coverage remained steady. They all worked in synergy with each other. The drivers include:

1. Cadre of community-centred health workers (categorised as a direct driver) - example: "In districts with improved coverage, community-centred health workers were instrumental in facilitating access to immunization through regular service provision that was planned in collaboration with communities."
2. Partnership between the health system and community (direct driver) - example: "In the improving districts, community volunteer networks were extensive and active, and volunteers regularly supported health workers without receiving formal compensation."
3. Regular review of programme and health worker performance (direct driver) - example: "Performance review was team-oriented and focused on problem solving. It encouraged constructive discussion, employed strategies of peer learning and friendly competition, and engendered collective accountability for improving RI. Combining data-based monitoring with non-threatening, transparent, learning-focused management techniques was highly motivating for health workers and community members."
4. Immunisation services tailored to community needs (direct driver) - example: "Transformation from driver to outcome happened when health workers responded to community demands and worked with the community regularly using local venues and communication channels. Health workers crafted the messages to reach different segments of the population: mothers, fathers, religious leaders, traditional leaders and local government officials. These strategies increased health worker credibility among community members, which resulted in better physical and socio-cultural access to care. Caretakers responded with increased attendance for immunization."
5. Political and social commitment to RI (categorised as an enabling driver)
6. Actions of development partners (also an enabling driver)

The discussion section of the paper echoes and emphasises that different countries have different pathways to coverage improvement. It is "how [countries] execute their programmes [that] seems to make a difference in coverage outcomes". Themes that emerged from this study of the drivers of immunisation coverage improvement include:

• Community-centred strategies
• Networks, partnership, and meaningful collaboration
• Efforts to motivate health workers
• Health and immunisation systems ("It is noteworthy that most of the drivers that directly influenced immunization coverage were not unique to immunization, but were equally relevant to other primary health care interventions.")

The ARISE approach was endorsed by the Task Force on Immunization (TFI) at the 2011 African Regional Conference on Immunization: "Recommendation #11: Countries are encouraged to focus on an assets-based approach that focuses on positive drivers which contribute to improved immunization coverage and systems." The work in this paper was supported by the Bill & Melinda Gates Foundation.