The Drum Beat 66: Immunisation - Africa

Communication for routine immunisation and polio eradication including National Immunisation Days (NID's), Expanded Programmes on Immunization (EPI's) and Acute Flaccid Paralysis (AFP) Surveillance was evaluated in 5 sub-Saharan countries during Oct and Nov 1999. The evaluation was a collaborative effort between 5 Ministries of Health, WHO, UNICEF, USAID, BASICS, CHANGE and JHU-PCS. Case studies include Democratic Republic of the Congo (DRC), Mali, Mozambique, Nigeria, and Zambia. Excerpts from the findings and examples follow. Thanks to Michael Favin at The Change Project.



Please click here for a summary of this evaluation work from this presentation from the "Why Invest in Communication for Immunization" Workshop given by Michael Favin in Washington, DC, United States in January 2004.



STRATEGIC ISSUES



1. SUSTAINABILITY: NID's have not been sufficiently integrated with routine immunisation and surveillance programmes. High levels of energy and resources are flowing into NID's while the Expanded Programme on Immunisation [EPI] efforts that will provide long term sustainable immunisation can be stagnating.



Zambia (p 14): Routine immunisation must often give way to ... emergency health issues [HIV/AIDS, malaria, cholera] or be integrated into a broader maternal health care package. ...Furthermore, it may be felt that immunisation efforts are being taken care of sufficiently through the NID's campaigns, which are a centrally planned activity with ample funding, staff and resources.



2. CONSTRAINTS: Resources, poor management, poor quality of service, and limited or no support for strategic communications.



Mozambique (p10): EPI has had to rely on mobile brigades, based in district seats, to provide minimal services in areas far from functioning facilities... only about half of public health facilities offer regular immunisation services... due to a lack of trained personnel, vaccine, spare parts and equipment about half of the health staff working in immunisation has received specific training.



3. COVERAGE: NID coverage figures are very good but questions exist regarding the population and target group data.



Mali (p 27): "Our commune did even better than many of the other communes in the region - their NID's only had coverage rates of 112 per cent or 115 per cent but ours reached 130 per cent"





Mozambique (p 20): ...coverage levels in the NID's and routine immunisation are overestimated, possibly by as much as 25 per cent.. [because] ... using population figures that are too low; outbreaks of measles and other immunisable diseases that indicate lower-than-official coverage; and ... many informants judge services to be deteriorating at a time when coverage is officially increasing.



4. LIMITED SURVEILLANCE: [With some exceptions] AFP surveillance is largely confined to health systems with very limited activities in support of community involvement.



Mali (p 26): Less than a week before the first round of the 1999 NID's ... the National Steering Committee heard about AFP surveillance for the very first time... The Committee has been responsible for guiding and overseeing the entire process of planning, preparing and implementing the NID's for three years...



5. FINANCING: Immunisation requires adequate and sustained funding including communication advocacy and social mobilization.



Mozambique (p 11): Most of Mozambique's EPI costs are donor funded. DANIDA was the predominant funder until 1996 ... routine services still suffer the effects of the war and the DANIDA pullout. The cold chain is aging and shrinking. A large investment is clearly needed to revive the routine programme.





Nigeria has an innovative approach (p 20): To assist with financing for immunisation activities, including NID's, the Nigeria Immunisation Fund was implemented ... the goal is to generate money for immunisation from private companies and partners who will donate to the fund...



COMMUNICATION ISSUES



6. INTERGRATED COMMUNICATION PLANNING: It is unclear how well planning incorporates previous recommendations and adequate demographic KAPB on low coverage populations is missing or non-existent.



Zambia (p 14): ... the report of the review carried out in 1997 has yet to be disseminated and discussed with districts. It is also unclear whether there exists adequate demographic and knowledge, attitudes, practices and behaviour (KAPB) data on the low-coverage populations to develop a focused communication strategy and action plan.





Mozambique (p 23): While people can be mobilised for a simple action such as participating in NID's, one cannot plan more complex communication or behaviour-change activities without an in-depth understanding of audiences - their current KAPB, the feasibility of changing current KAPB, barriers to change and motivators/facilitators to change. Clearly, more in-depth research is needed...



7. ANALYSIS AND CHOICE: A mix of communication channels is used including interpersonal communication, mass media, drama, song and dance, and local leadership.



Mali (p 15): NID's' social mobilisation and communication strategies utilized a mix of media, including radio, television, newspapers, t-shirts, banners, stickers and interpersonal communication ... television and radio have been the media of choice [for investment] .... This strategy would be more effective ... if the coverage rates, gender and other characteristics of target audiences were more carefully considered.



8. CULTURE: Cost effective communication needs to be based on greater balance between the proportion of funds allocated to the production of costly materials (TV spots, banners, stickers) that reach, mobilize, and educate a minor percentage of the population versus those that reach a large number of the population (radio) and that are more likely to be culturally appropriate such as traditional channels and Interpersonal
Communication (IPC). This means the involvement of community leaders; ... strategic and more cost effective communication activities; and taking into account gender differences...



9. DECENTRALISATION: There is a trend to decentralisation of planning but with mixed results. This allows for adaptation for local audiences but also can lead to message inconsistency...[and]... Centralized production of communication materials provides consistency of message but has led to weak adaptation of materials to local population needs.





10. INTERPERSONAL COMMUNICATION AND MASS MEDIA: In most cases IPC remains the most culturally and linguistically appropriate channel.



Mali (p 13): Many women interviewed, particularly in rural areas, did not learn about the NID's from any of the media and materials developed for the communication and social mobilisation strategies . ... in the Mopti region [interviews] suggest that women usually learned about the NID's at the very last minute while they were at home or on their way to wells, fields and marketplaces. Women received this information by word of mouth from other women, on the first morning of the NID's.



11. MOBILISATION: Zambia is recognised for high-sustained levels of immunisation coverage despite a lack of staff and resources... [because] other sectors (schools and religious organisations) support the health system; the rules or laws used to reinforce behavioural change; and...the immunisation card.



12. CONFLICT SITUATIONS: Immunization in the DRC saw major improvements in polio eradication in 1999 due in part to: a cease-fire obtained through the joint effort of government and the international community; instructions given to the army to facilitate vaccine distribution and vaccinator mobility; strong support from international media; and duplication of central coordinating structure and extra resources for occupied areas.





OVERALL RECOMMENDATIONS



A. Improve the availability of reliable immunisation coverage data
B. Strengthen health education
C. Improve the integration of routine EPI and surveillance of AFP with polio eradication activities
D. Dedicate resources to conducting quality research
E. Develop more strategic communication interventions
F. Increase and sustain community participation in polio eradication and EPI
G. Take advantage of momentum and structures created by NIDs to improve routine EPI
H. Strengthen monitoring and evaluation and supervisory systems
I. Develop a culture of client-oriented health services
J. Institutionalise partnership with media
K. Develop a long-term partnership with the private sector


SYNOPSIS



13. Follow-up to this report include incorporation of findings into country plans for Mozambique and Mali, presentation to Task Force on Immunisation and social mobilisation meeting, incorporation into "Checklists and Easy Guides for Communication for Polio Eradication" and copies to be sent to national EPI managers.



DOCUMENTS

The summary document is posted on the UNICEF website in English and French (and soon Portuguese)

Individual country studies can be requested from Modibo Kassogue in
UNICEF/NY mkassogue@unicef.org or Grace Kagondu kagondug@whoafr.org or
Margaret Matthai matthaim@whoafr.org both at WHO/AFRO.



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This Drum Beat compiled by Chris Morry cmorry@comminit.com

Please send items for The Drum Beat to the Editor - Deborah
Heimann dheimann@comminit.com