Strengthening Routine Immunization in Papua New Guinea: A Cross-sectional Provincial Assessment of Front-line Services

Low routine immunisation coverage in Papua New Guinea (PNG) has contributed to disease outbreaks such as measles and the polio that re-appeared after a 20-year hiatus in 2018. This paper reports on a cross-sectional health services assessment investigating PNG government efforts to improve routine immunisation prior to the polio outbreak. The study focused on modifiable aspects of frontline services, recognising that, for coverage to increase, strategies to strengthen health system elements must ultimately enable changes in service delivery and uptake.

PNG had in 2015 introduced the Special Integrated Routine EPI Strengthening Program (SIREP), which sought to improve programme performance amidst the major challenges facing PNG's health services, such as a stretched health workforce, financial constraints, and dispersed rural populations with minimal road access. SIREP had 4 priorities: more efficient local planning based on locations of child populations, intensification of outreach services with realistic scheduling based on local resources, improved local information systems (including child health books), and staff training to support new vaccine introductions (most prominently Inactivated Polio Vaccine (IPV) as well as pneumococcal and rubella vaccines). SIREP also aimed to integrate other primary health care with vaccination and to merge the programme intensification often seen in emergency campaigns with internationally proven strategies for routine programming, such as those collated by WHO in "Reaching Every District (or Community)" approaches and the Global Routine Immunization Strategies and Practices (GRISP) framework.

In East New Britain province (ENBP), the researchers carried out a cross-sectional assessment of health facilities, staff, and clients of 12 clinics providing immunisation services from November 2016 to January 2017, timed to follow the initial rounds of SIREP training and implementation. Research methods, which were informed by theory-based evaluation, a WHO quality checklist, and other health services research tools, included semi-structured interviews, focus group discussions (FGDs), records review, and structured observations.

The researchers documented strengths and weaknesses across 6 categories of programme performance relevant to national immunisation strategy and global standards. In general, an immunisation service with an operational level of staff, equipment, and procedures was found to be in place, but it could reach only half to two-thirds of its intended population. While most staff provided a clean and effective vaccination injection, there were gaps in provision of education, counselling of families, adverse event following immunisation (AEFI) readiness, and the checking of vaccines for heat or freezing damage. Several missed opportunities for vaccination were noted.

Community engagement activities consisted of group education talks at 25% of clinics, but without use of pictorial, video, participatory, or take-home communication products. Local communities donated in-kind support to some clinics, but there was no structured engagement, nor use of trained community health volunteers to help with organisation, mobilisation, or education. Some families (4/10 groups) sought more respectful staff-client interactions. Male parents or caregivers were rarely involved in immunisation visits; staff cited embarrassment as a constraint. Community members reported lack of support from family members as an occasional barrier to vaccination.

All participants (staff in interviews and community members in discussions) described local strengths or suggested improvements. Common ideas proposed by staff included more personnel, stronger support for transport needed to do outreach, better community engagement, more active community education, involvement of male parents or caregivers, and the offering of extra services for both mother and baby. Caregivers sought more frequent, reliable, and "on-demand" services, especially outreach, noting travel time and costs as a common barrier to uptake. Mothers, more often than staff, asked for the addition of family planning, promotion of reproductive health, and maternal illness care at immunisation clinics. ("If integrated service provision prioritises care that families want, this may help build demand for and confidence in immunization services, as well as meeting their felt needs.")

Based on the findings, the researchers propose 10 actions, 6 of which were already embedded in the SIREP strategy (and hence in national immunisation plans) but were insufficiently resourced or implemented in the study setting. Examples include: supportive supervision linked to refresher training including good communication and AEFIs (already in SIREP), and health communication products and programmes to educate families on the complete vaccine schedule.

In the area of community engagement and mobilisation, in particular, the resarchers suggest increased group and individual counselling in the vaccination encounter and the creation and provision attractive, durable, "take-home" information products, aiming to build community demand for a timely, complete schedule of vaccination. Outreach can benefit from stronger, formalised involvement of local leadership, possibly with the deployment of trained lay health workers; such community resources can also help register and track children needing vaccination. Vaccination support by trained lay health workers, termed "Village Health Volunteers" in PNG, has been proven in this country in the past.

PNG's 2018 polio outbreak has necessitated a major emergency response, with national and sub-national campaigns initially for polio vaccination alone and later with other antigens. Such emergency responses or campaigns could synergise with the proposed actions to strengthen routine immunisation. For example, campaigns and emergency responses could also work for stronger community engagement, including communications with local leaders and trained health volunteers that advocate for long-term support to the continuing routine programme. Other practical support could address the planning and information gaps noted in the study, by distributing Child Health Record Books, staff immunisation manuals, and other key knowledge resources needed by the routine programme.

In conclusion: "The national strategy addresses most local gaps, but implementation and resourcing requires greater commitment. Long-term strengthening requires a major increase in centrally-allocated resources, however there are immediate locally feasible steps within current resources that could boost coverage and quality of routine immunization especially through better population-based local planning, and stronger community engagement."