Immunisation program reviews in East and Southern Africa: 2012-2018; key lessons
Messeret Eshetu Shibeshi1,&, Balcha Girma Masresha2, Fussum Daniel1
1World Health Organisation, Inter-Country Support Team for East and Southern Africa, Harare, Zimbabwe, 2World Health Organisation, Regional Office for Africa, Brazzaville, Congo
Messeret Eshetu Shibeshi, World Health Organisation, Inter-Country Support Team for East and Southern Africa, Harare, Zimbabwe
World Health Organisation (WHO) recommends that countries conduct comprehensive national immunization programme reviews regularly to help them identify systems wide-barriers or gaps, and monitor performance against the set targets.
we reviewed reports from the latest national immunization program reviews conducted in the 20 countries in the subregion in the course of 2012-2018. We generated descriptive analysis of the findings across the subregion.
the 20 program reviews included field observations to the subnational levels as well as interviews with program staff and stakeholders. At the time of the reviews, only 11 countries had functional National Immunisation Technical Advisory Groups. Operational funding was inadequate in half of the countries. The reviews documented the cancellation of outreach services, supportive supervision visits and maintenance of cold chain equipment due to the lack of fuel or operational funding. Immunization programs in 10 countries had major human resource gaps. Vaccine stock management tools were not effectively used in 10 countries, and stockout of vaccines and supplies was documented in 9 countries during the review. The full components of the RED Strategy were implemented in only 3 of the 20 countries. Twelve countries reported challenges with the availability and accuracy of target populations. Four countries had documented the presence of vaccine hesitant groups at the time of the reviews.
the reviews demonstrated challenges in various aspects of the programs in different countries. The implementation of the review recommendations should be built into the annual program plans, as well as into costed multi-year plans, in order to address the gaps and helps the program to attain the set targets. With the rapid evolution of the scope and complexity of the immunization programs in recent years, countries should invest their efforts in building the capacity of their human resources as well as updating their logistics and data systems.
In May 2012, the World Health Assembly (WHA) endorsed the Global
Vaccine Action Plan (GVAP) . The World Health Organisation
(WHO) African Region adopted a seven-year immunisation strategic
plan (2014-2020) aligned to the GVAP . Countries
in the Region have developed and are implementing national strategic
and annual action plans
following the principles and targets of the GVAP and the Regional
strategic plans. To determine progress towards the set milestones
and targets, and
to align program activities, countries regularly monitor vaccination
coverage, disease trends and other programmatic indicators at national
As part of the effort to strengthen the governance and leadership of national
immunization programs, countries are expected to establish organs
including the National immunization Technical Advisory Group (NITAG)
independent technical experts responsible for generating evidence-based
policy guidance and technical recommendations; the Inter-Agency
Coordinating Committee (ICC) which brings the national authorities
together with the
various donors and technical partners, and is a platform for endorsing
program plans, advocating and mobilizing resources; and the National
Regulatory Authority (NRA) that ensures the appropriate registration of
vaccines for use in the country [3-5].
On the operational aspects, WHO advises countries to implement the Reaching Every
District (RED) approach to be able to reach all communities and
all children, including those who normally do not access health
services, and thus to
assure equity in immunization service delivery. The RED approach
comprises of establishing outreach services; conducting regular
linking services with communities; monitoring and using data for
action; and the management of resources .
The monitoring of vaccination service delivery data is done by recording the
number of doses of antigen delivered in each health facility and aggregating
it at the district, provincial and national levels. Administrative coverage
is calculated by dividing the number of doses provided by the target population
(the number of surviving infants for the calendar year) for the particular
catchment area. The target population is generated from census data or from
projections made based on recent census data. Considering the challenge with
the accuracy of numerator and denominator information, WHO and UNICEF generate
annual estimates of coverage for each antigen for each member State using the
provided administrative data, information from coverage surveys, logistics
information and other programmatic data. These WHO estimates are only generated
for the national level . Data quality assessments are
conducted regularly to assist countries to identify challenges with the data
management system and be able to troubleshoot using the data quality .
WHO recommends the periodic conduct of comprehensive national immunisation programme
reviews (EPI reviews) to help countries identify system-wide barriers or gaps,
monitor performance against the set targets, and develop strategic direction
to remove these barriers or gaps towards the development of a more robust and
resilient program . These program reviews, conducted
every 4 to 5 years, constitute a holistic assessment of the strengths and weaknesses
of the Immunization Programme at national, sub-national and service-delivery
levels. The reviews are done with the participation of various technical partners,
and provide the evidence to align the immunization program´s strategic
directions and priority activities which are then translated into comprehensive
Multi Year Plans (cYMP), and subsequent annual program plans, and as advocacy
tools to reinforce the engagement of the leadership within the respective Ministries
of Health [8,9]. Countries supported
with GAVI funding undertake annual joint appraisal exercises with a focus on
grant monitoring and overall progress towards program goals. These appraisals
do not substitute for comprehensive program reviews .
The Eastern and Southern African subregion of the WHO consists of 20 Member States,
a subset of the 47-member State of the WHO African region. These countries
are Botswana, Comoros, Eritrea, Eswatini, Ethiopia, Lesotho, Kenya, Madagascar,
Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South
Sudan, Tanzania, Uganda, Zambia, and Zimbabwe. Between the years 2014 - 2018,
all of the twenty countries in the sub-region conducted at least one comprehensive
Immunisation Program review .
This manuscript attempts to summarize the strengths and weaknesses of the immunization
programmes in the countries in the subregion, as documented in the program
reviews, with a view to highlight actions required for countries to progress
towards the programmatic targets.
Comprehensive Immunization Program Reviews are cross-sectional program assessments that are conducted through the review of documents and data, the interview of immunization program staff at national and subnational levels, as well as field visits to provinces, districts and to service delivery sites. The data from the program review is collected using standardized data collection tools developed by WHO AFRO, which are adapted to the individual country context. The tool includes sections that cover the following thematic areas: (i) Leadership, governance and coordination (ii) Human resource management, capacity building and supervision (iii) Vaccine supply quality, logistics and cold chain (iv) Service delivery (v) Data monitoring, immunization quality and Vaccine preventable diseases surveillance (vi) Demand generation, social mobilization and Advocacy. At the end of a program review, the findings and the recommendations are compiled by the review team in a formal report and presented to the respective Ministry of Health.We reviewed the detailed narrative technical reports generated from each of the national immunization program reviews conducted in the 20 countries in the subregion in the course of 2014-2018. We conducted a descriptive analysis of the findings from the review exercises and attempted to do a summary of the findings by thematic areas.
Each of the 20 countries conducted at one national immunization program review between 2012 and 2018 (Table 1). These 20 program reviews included field observations to a total of 137 Regions, 314 districts and 718 health facilities. In addition, the reviews included interviews with 475 program staff and stakeholders from the national levels, 1,028 immunization session observations, and also exit interviews with 1,435 care-givers. The field observations included verification of the existence of relevant plans, guidelines and tools, as well as supervision of immunization services delivery, cold chain and vaccine management practices. The major findings from these reviews are summarized below.
Leadership, governance and coordination:
at the time of the program reviews, 16 of the countries (80%) had some sort of legislation promoting immunization, and 13 (65%) had updated immunization policy documents. All except one country had updated comprehensive multi-year plans for immunization (cMYPs).
Full government financing of the immunization program was documented in the 6 countries while 14 countries (which were GAVI eligible) depended on complementary support from partners such as Gavi for new & underutilized vaccines and UNICEF for the purchase of traditional vaccines. Immunization services were provided free of charge in public health institutions in all countries.
In the area of coordination, only 11 countries had functional National Immunization Technical Advisory Groups (NITAG), while 17 countries had National Regulatory Authorities (NRA) at the time of the review. The 6 self-financing countries did not have functioning Inter-Agency Coordination committees (ICC), while in 10 of the remaining 14 countries, the ICC was playing a key role in the coordination of partner support to the national immunization program. The level of coordination between the immunization program and the unit responsible for disease surveillance was limited in 8 of the 20 countries.
Operational funding was inadequate in half of the countries in the sub-region. The reviews documented the cancellation of outreach services as well as the regular conduct of supportive supervision and maintenance of cold chain capacity at sub national level in these countries, mainly related to the lack of fuel or funds to rent vehicles.
Human resources management, capacity building and supportive supervision:
ten (50%) countries had gaps in the number of staff and the skill mix required to run an efficient immunization program at national and sub-national levels. These countries also lacked clear terms of reference or job descriptions for the assigned focal persons who were engaged in the day-to-day management of the immunization program at different levels.
Seventeen countries (85%) had clear plans for program supervision. However, supervisory visits to the subnational levels were inadequate or irregular in 4 of these 17 countries, due to limitations in funding and means of transport. Standardized tools for the supervision of immunization services were available in only 14 of the 20 countries.
Vaccine and cold chain logistics:
vaccine stock management tools were not effectively used in 10 (50%) countries, with tools lacking or outdated or not used regularly to monitor vaccine stocks at the health facility levels. Stockout of vaccines and supplies at the sub national level, lasting more than 3 months, was documented in 9 (45.0%) countries during the review. It was documented that 4 countries had frequent power interruptions and inadequate backup generators. Five countries did not have an updated cold chain equipment inventory system and no cold chain rehabilitation /replacement plan at the time of the review. The cold chain capacity was considered inadequate according to the reviews in 4 countries mainly at the sub national level (Table 2).
the full components of the RED Strategy were implemented in only 3 of the 20 countries (15%). At the time of the reviews, 14 countries (70%) did not have up-to-date operational level micro-plans for routine immunization services. In addition, 9 (45.0%) countries were not able to organize outreach services as planned due to transport and field staff constraints. Five (25.0%) countries also did not have enough cold chain equipment to run outreach services. At the time of the reviews, three countries had not yet introduced AD syringes for use in their immunization programmes. Defaulter tracing mechanisms were available in only 12 (60%) countries (Table 3).
Coverage monitoring, disease surveillance and data quality:
the availability and accuracy of target populations has been reported as a major challenge in 12 (60.0%) out of the 20 countries. Besides, the review in ten countries detected gaps in the systematic use of data for decision making, especially at the district and Health Facility levels, linked mostly due to knowledge gaps and limited resources. Data quality review and data harmonization meetings were held regularly in 13 (65%) countries. Seven countries reported major challenges with their monitoring systems. These included denominators projected from outdated census causing significant over or under-estimation of the real target population, too many monitoring tools, discrepancies in the data across different administrative levels, as well as limited time and capacity to analyse and use data for decision making (Table 4).
The reviews in 10 of the countries also documented gaps among health workers in the basic knowledge required to run effective surveillance systems. These included gaps in the understanding of standard case definitions for priority conditions, the core performance indicators for the surveillance of Vaccine Preventable Disease and the various epidemiological concepts in use in the surveillance system. All except one country had annual VPD surveillance plans at the time of the review. National expert committees for Adverse Events Following Immunisation (AEFI) were in place in 16 countries (Table 5).
Demand generation and social mobilization:
fifteen countries had a communication strategy for the immunization program. A written plan to address crisis /risk communication was available in 17 (85.0%) countries. In 5 countries, it was noted that communication efforts were well developed for new vaccines introduction and supplemental immunization activities (SIA) but quite weak in promoting Routine Immunisation and community surveillance. Four countries had documented the presence of vaccine hesitant groups at the time of the reviews. Four (20%) of the 20 countries did not have communication messages tailored to address specific groups.
The findings in this summary have been aggregated and no specific country detail is given, since the main objective of the study was to demonstrate the challenges countries face in general. Moreover, since the reviews took place in the years 2012-2018, it is expected that any gaps have been addressed by the specific countries following the review exercise. While 12 of the 20 reviews were conducted in the last 5 years, 40% were conducted more than 5 years ago indicating the need for timely program reviews to steer the programs in the right direction.
Immunisation program reviews cover a broad scope of program area but may not always achieve the necessary depth given the limited time allocated to the exercise [8,9]. When in-depth reviews are needed, countries utilize the focused review tools that cover specific program areas which may include vaccine management practices, new vaccine introduction process and outcomes, surveillance performance, data quality or others [9,12].
The 20 program reviews covered in this study indicated that some countries did not have any legislation or policy framework for immunization. Having the appropriate legislative framework helps countries to protect national immunization budgets and also to address community demand for vaccines . Similarly, the lack of functioning and vibrant Inter-agency Coordinating Committees may affect the coordination of activities among the partners as well as the effective mobilization of resources. Effective oversight and coordination of immunization programmes by government and partners are critical to achieving national immunization goals. National coordination forums, including ICCs and health sector coordinating committees play an essential role in this work [14,15].
The growing complexity of the immunization area of work in the last two decades requires the presence of strong human resources with the necessary managerial skills and tools. Findings from the reviews show that half of the countries were experiencing limitations in their human resource capacity within the national program and at sub-national levels. Health worker training plays an important role in improving overall performance including vaccination coverage [16,17]. Other studies and program reviews have also shown the critical role of human resource in immunization program delivery [18-20].
In the 20 program reviews in this sub-region, capacity gaps are also reflected in the lack of clear managerial tools (eg., terms of reference, job descriptions and standard orientation/training for newly assigned focal persons). Inadequate supportive supervision and the absence of standard supervisory tools are other common challenges. Supportive supervision has been shown to be an important component in immunization programmes [21,22].
Regarding vaccine management logistics, half of the countries in the sub-region were not using the standard stock management tools, which are critical for monitoring stock levels, vaccine utilization, vaccine wastage, and forecasting needs. The reported stockouts of vaccine and supplies in nearly half of the countries in this review are important from the point of view of the missed opportunities for the respective antigens the gaps created. The finding is comparable to the study that documented 38% countries in Sub-Saharan Africa experienced at least one national-level stockout event for at least one vaccine and for at least one month during 2015 .
In a study focused at the district level in 3 African countries, LaFond et al. have identified six common drivers of routine immunization coverage improvement. These include the presence of a cadre of community-centered health workers, health system and community partnership, regular review of health workers performance, the delivery of immunization services tailored to community needs, political commitment to routine immunization, and the actions of development partners. The study claimed that the presence of all six factors together was found to have positive impact in terms of coverage improvements . The finding from the 20 national immunization program reviews indicated that not all of these enabling components of good quality immunization program performance were being implemented at district level in some of the countries.
It is well known that service factors and parental attitudes and knowledge are
some of the most important reasons for non-vaccination. Among the service factors,
Favin et al. have found that geographic inaccessibility of services,
vaccine stock-outs and/or cold chain problems accounted for the majority of
missed opportunities for the vaccination of children in many countries .
A lot of challenges exist with regards to immunization data monitoring and quality
in the African region. This review has identified the main challenges including
knowledge gaps, discrepancies in data at different levels, and weak capacity
to use data for decision making. Some of the root causes of challenges in monitoring
systems include the lack of sustainable resources for immunization, logistical
limitations, and the lack of reliable denominator data for planning and coverage
The reviews documented serious gaps in the surveillance for Vaccine Preventable
Diseases (VPDs) related to limited knowledge of health workers, inadequate
resources and programmatic focus. Gaps were documented in the prioritization
for active surveillance, as well as in the monitoring and use of surveillance
data, as reported in other studies in the African Region [27,28].
The presence of population groups hesitant towards vaccination documented in
4 countries is a growing challenge that has in the past contributed to disease
Noting the complexity of vaccine hesitancy and the limited evidence available
on how it can be addressed, identified strategies should be carefully tailored
according to the target population, their reasons for hesitancy and the specific
Limitations of the study:
these national immunization program reviews were conducted using similar approaches
and tools, but the review was conducted by different teams and using tools adopted
for the national context. This may result in differences in the formulation of
the review questions and interpretation of data. During these reviews, the sampling
of subnational units was done purposively to strike a balance between urban and
rural districts as well as strong performing and weaker districts. Therefore,
all the results may not be comparable across the countries. In addition, it is
expected that the countries will have acted upon the review findings and made
the necessary program changes since the reviews, and so the results may not reflect
the current situation at country level at the time of publication.
The national immunization program reviews in the sub-region have been
useful tools to identify barriers or program gaps and generate recommendationsfor
the national program and local partners to address the barriers or
gaps. The reviews in the subregion have demonstrated challenges with regards
various aspects of the programs in different countries and unless addressed
they will fail short to ensure provision of equitable immunization
service delivery. The follow up of recommendations to address the challenges
gaps constitutes an essential component of the review exercise aiming
to enable them to attain the set targets. Countries should invest in continuous
and systematic capacity building, in the context of the continuously
and expanding immunization program. in this context, we also recommend
that countries should plan for and conduct EPI program reviews at least every
4-5 years, preferably timed to provide inputs into program plans along
setting up mechanisms to regularly monitor program performance and
address gaps, as well as to follow up and implement recommendations from
review exercises. These
EPI reviews may not constitute an in-depth evaluation of all program
components, indicating the need to tailor the implementation of the reviews
aspects of the program, based on the country context and preliminary
findings. In addition, as necessary, countries may plan to conduct in-depth
and root cause analyses.
What is known about this topic
- Comprehensive national Immunisation Program Reviews are conducted once every 4 to 5 years in low- and middle-income countries, in order to identify program areas for improvement, realign program focus as necessary and prepare the program for the introduction of additional program elements;
- Comprehensive program reviews are complementary to reviews with in-depth focus on specific program components;
- Recommendations generated by program reviews help countries to focus their efforts to address major program gaps.
What this study adds
- With the rapid evolution of the scope and complexity of the immunization programs across the Region, countries should build in methods to regularly review program performance and develop their strategic directions with the required investments for program sustainability and also invest in capacity building;
- A significant proportion of National immunization programs in the subregion continue to have gaps in their implementation of the Reaching Every District Approach, in their human resource capacity, as well as in their logistics and data management systems;
- The follow up of the review recommendations will be critical to address the identified system-wide barriers or gaps in order to strengthen the immunization program and enable it to attain the objectives.
The authors declare no competing interests.
All the authors have read and agreed to the final manuscript.
We would like to acknowledge the efforts of the national immunisation program staff, partners and stakeholders who took part in these extensive program reviews across the years. We thank the WHO immunisation program staff from the global, regional and subregional levels who coordinated the different reviews. We also thank Professor Tanimola Akande (University of Ibadan, Nigeria) and Mr. Stanley Diamenu (Ghana) for their valuable review of an early draft of the manuscript.
Table 1: period of latest National comprehensive EPI program review by country; Eastern and Southern Africa subregion (2012- 2018)
Table 2: summary of findings on Vaccine management and Cold Chain systems
Table 3: summary of findings on Immunisation Service Delivery
Table 4: summary of findings on Immunisation Monitoring systems
Table 5: summary of findings on Vaccine preventable Diseases surveillance
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