Authors: Isabeaux Kennedy Mitton, Lior Miller, Leah Ewald, Maria Francisco, Dr. SOW Mamadou Kaba, and Dr. GBEASOR-KOMLANVI Fifonsi

Ensuring equitable immunization coverage can be challenging for low and lower-middle-income countries as low immunization coverage is linked to underperforming health systems in both urban and rural areas and community misconceptions and mistrust of existing immunization programs. By integrating immunization services with community health, countries can capitalize on community-based strategies and community health workers to increase and improve access to immunization services. 

Guinea and Togo, where the Accelerator supports strengthening the immunization system to improve routine immunization coverage and equity, have implemented community health strategies to empower communities within the health system and improve the access, quality, and equity of health services. As of 2021, 38% of children in Guinea and 13% in Togo received zero doses of DTP1.  During the Accelerator’s early consultations with country partners from Togo and Guinea, both countries signaled interest in learning from each other’s experiences of integrating community health and immunization as a strategy for improving immunization coverage.  

On April 22, 2022, the Accelerator facilitated a virtual dialogue between 23 key stakeholders from Guinea and Togo. Participants discussed strengths and weaknesses within their countries’ immunization and community health systems and how these two systems can be further integrated. The objectives of this dialogue were to: 

  • Understand, in practical terms, what immunization and community health integration may look like in Guinea and Togo and the potential benefits for both programs.
  • Consider the needs and implications for integration across the building blocks of the health system (financing, leadership and governance, human resources, physical infrastructure, coordination, service delivery, and community engagement).
  • Identify common challenges and pitfalls related to immunization and community health integration (drawing on experiences integrating community health with other programs).
  • Share practical strategies both countries have successfully used to integrate community health with other health programs, especially immunization.
  • Identify needs for further learning around community health and immunization integration.

Participants included officials from Togo and Guinea’s Ministry of Health Immunization, Community Health, and Planning Divisions, partners including WHO, UNICEF, Integrate Health, Priority Health Guinea, and representatives of civil society organizations. 

The virtual dialogue began with a discussion of a framework for community health and immunization integration, which featured three successful integration examples— India’s National Rural Health Mission2, Kenya’s Community Health Strategy3, and Sierra Leone’s Integrated Community Case Management program4. The framework grounded the participants’ understanding of improving immunization coverage at the systems level. It also helped them explore how integration can be viewed across the six building blocks of a health system.  

Expanding the WHO’s Health Systems framework to include community health and immunization integration across all six building blocks of the health system
Figure 1: Expanding the WHO’s Health Systems framework to include community health and immunization integration across all six building blocks of the health system

Following the framework’s presentation, Guinea and Togo participants shared information on their countries’ immunization services and proposals on better integrating community health and immunization. Bringing together these francophone countries from the West Africa region into a shared space was a valuable experience for both countries as it allowed Togo and Guinea to strategize over their shared challenges and learn from their differences—where Togo has higher coverage rates for certain routine immunizations, Guinea has a more developed community health policy with established groundworks for community health and immunization integration: 

  • In line with Guinea’s National Community Health Policy, Guinea hopes that by developing the capacity of all health workers, improving vaccine availability and accessibility, and expanding the geographical coverage of immunization sites, they can address coverage challenges that resulted in a drop in fully immunized children from 37% in 2012 to 30% in 2018. Guinea also shared ongoing community health strategies to improve immunization coverage and equity, such as the ‘École des Maris’ (School for Husbands), which is an approach aimed at involving men in the promotion of maternal and child health, which includes decision-making about immunizing children. In addition, Guinea is engaged in discussion about the sustainability of institutionalizing CHWs as paid staff following the passage of the National Community Health Policy. CHWs’ salaries are supposed to be financed by the government. However, they are often paid by partners and donors or not paid at all. In exploring potential solutions to ensuring salaries are paid, Guinean partners expressed interest in learning about Togo’s national budget line for community health.  
  • In Togo, immunization coverage for all antigens is 80%, except for measles-rubella 2 (MR2) and tetanus-diphtheria (Td2+). Despite Togo’s relatively high immunization coverage rates, immunization accessibility and coverage in Togo varies by region (the Grande-Lomé and Maritime regions have the lowest immunization coverage, with 57% and 56% MR2 coverage, respectively). Similar to Guinea’s ‘École des Maris,’ Togo’s Platform of Civil Society Organizations for Vaccination and Immunization (POSCVI) uses the ‘Papa Champion’ strategy where husbands, with the support of local health centers, conduct visits to households where family members express hesitancy or reluctance to immunization. Other community health and immunization integration strategies to improve equitable access to vaccines in Togo include efforts to improve the training, treatment, and financial compensation of CHWs in Togo. Integration also includes active participation from actors within the community health system, including community health workers, community relay workers, NGOs, civil society organizations, traditional and religious leaders, and sectoral committees. 

From India, Kenya, and Sierra Leone’s community health and integration examples, there is supporting evidence that CHW engagement in immunization services (for example, via social mobilization and communication, referrals, and in some cases, direct provision of vaccination services) leads to improved routine immunization coverage in low-resource settings. Below are some key findings and lessons learned from these case studies, which were shared with the participants during the framework presentation:  

  • CHWs play a crucial interface between communities and health systems due to their trusting relationships with community members. CHWs can easily identify tensions and communication gaps between healthcare workers and the populations they serve, which typically lead to feelings of mistrust and misunderstandings4
  • CHWs can increase demand for immunization services by informing communities of the services they are entitled to, which both promotes accountability of the community health system and empowers community members1
  • CHWs can improve routine immunization coverage by promoting larger service packages, including maternal and child health services, health education and counseling, insecticide-treated bed nets, and immunization services.3
  • Barriers to the successful integration of CHWs into immunization services include systems-level challenges, such as inadequate cold chain equipment, lack of supportive supervision, failure to analyze reported data, inadequate funds, and the inability of local health centers to meet the needs of the rising population levels2.   

Despite evidence in support of integrating CHWs with immunization services from the three country case examples, there is still a gap in the literature of high-quality studies demonstrating an association between more integrated immunization and community health services with improved routine immunization coverage.  Existing literature on the impact of integration is either outdated or includes low-quality evidence. Given the strong commitments by Guinea and Togo to increase and improve the integration of CHWs in immunization work, both countries have an opportunity to explore the possibilities and benefits of integrating community health and immunization and contributing to the literature and country-level evidence of successful integration models. 

We are grateful for the active engagement from our participants, presenters, and facilitators. Stakeholders were eager to continue these exchanges and share country policies and resources to adopt good practices and lessons learned.  A second virtual dialogue on effectively leveraging immunization campaigns for routine immunization strengthening took place in June 2022. 

References: 

  1. Gavi staff, (2021). The Zero-Dose Child: Explained | Gavi, the Vaccine Alliance. https://www.gavi.org/vaccineswork/zero-dose-child-explained
  2. Pandey, P., Sehgal, A. R., Riboud, M., Levine, D., & Goyal, M. (2007). Informing Resource-Poor Populations and the Delivery of Entitled Health and Social Services in Rural India: A Cluster Randomized Controlled Trial. JAMA, 298(16), 1867–1875. https://doi.org/10.1001/jama.298.16.1867
  3. Nzioki, J. M., Ouma, J., Ombaka, J. H., & Onyango, R. O. (2017). Community health worker interventions are key to optimal infant immunization coverage, evidence from a pretest-posttest experiment in Mwingi, Kenya. The Pan African Medical Journal, 28, 21. https://doi.org/10.11604/pamj.2017.28.21.11255
  4. Enria, L., Bangura, J. S., Kanu, H. M., Kalokoh, J. A., Timbo, A. D., Kamara, M., Fofanah, M., Kamara, A. N., Kamara, A. I., Kamara, M. M., Suma, I. S., Kamara, O. M., Kamara, A. M., Kamara, A. O., Kamara, A. B., Kamara, E., Lees, S., Marchant, M., & Murray, M. (2021). Bringing the social into vaccination research: Community-led ethnography and trust-building in immunization programs in Sierra Leone. PLOS ONE, 16(10), e0258252. https://doi.org/10.1371/journal.pone.0258252