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 immunisation programme reviews regularly to help them identify
systems wide-barriers or gaps and monitor performance against the set
we reviewed reports from the latest national immunisation 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
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. Immunisation programs in 10 countries had major human resource
gaps. Vaccine stock management tools were not effectively used in 10
stockout of vaccines and supplies was documented in 9 countries during
the review. The full components of the Reaching Every District (RED)
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
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
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 immunisation
in recent years, countries should invest their efforts in building the
capacity of their human resources as well as updating their logistics and data
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
immunisation programs, countries are expected to establish organs
including the National Immunisation 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
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 immunisation 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 immunisation programme at the 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 immunisation 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 summarise the strengths and weaknesses of the immunisation
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 Immunisation Program Reviews are cross-sectional program
assessments that are conducted through the review of documents
and data, the interview of immunisation program staff at national
and subnational levels, as well as field visits to provinces, districts
sites. The data from the program review is collected using standardised
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
logistics and cold chain; (iv) Service delivery; (v) Data monitoring,
immunisation quality and vaccine preventable diseases surveillance;
(vi) Demand generation,
social mobilisation 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 immunisation
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 immunisation 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 immunisation 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,
well as supervision
of immunisation services delivery, cold chain and vaccine management
practices. The major findings from these reviews are summarised below.
Leadership, governance and coordination:
at the time of the program reviews, 16 of the countries (80%) had some sort of
legislation promoting immunisation, and 13 (65%) had updated immunisation policy
documents. All except one country had updated comprehensive multi-year plans
for immunisation (cMYPs).
Full government financing of the immunisation 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 and underutilised vaccines and UNICEF
for the purchase of traditional vaccines. Immunisation services were provided
free of charge in public health institutions in all countries.
In the area of coordination, only 11 countries had functional National Immunisation
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 immunisation program. The level of coordination
between the immunisation 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 immunisation 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
immunisation 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. Standardised
tools for the supervision of immunisation 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 immunisation services. In
addition, 9 (45.0%) countries were not able to organise 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 immunisation programmes. Defaulter tracing mechanisms were available
in only 12 (60%) countries (Table
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 harmonisation meetings were
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
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 (VPD) 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
Demand generation and social mobilisation:
fifteen countries had a communication strategy for the immunisation 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 Immunisation 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 utilise 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 immunisation. Having the appropriate
legislative framework helps countries to protect national immunisation 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 mobilisation of resources. Effective oversight and coordination of
immunisation programmes by government and partners are critical to achieving
national immunisation 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 immunisation 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 immunisation 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 (e.g., 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 immunisation 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 utilisation, 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 on the district level in 3 African countries, LaFond et
al. have identified six common drivers of routine immunisation 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 immunisation services tailored to community needs, political
commitment to routine immunisation, 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 immunisation program reviews indicated that
not all of these enabling components of good quality immunisation 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 immunisation 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 immunisation, 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 prioritisation
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 immunisation 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 immunisation program reviews in the sub-region have been
useful tools to identify barriers or program gaps and generate recommendations
for the national program and local partners to address the barriers
or gaps. The reviews in the subregion have demonstrated challenges
with regards to
various aspects of the programs in different countries and unless addressed
they will fail short to ensure provision of equitable immunisation
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
and expanding immunisation program. In this context, we also recommend
that countries should plan for and conduct EPI program reviews at least
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 towards specific
aspects of the program, based on the country context and preliminary
findings. In addition, as necessary, countries may plan to conduct
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 immunisation
programs across the Region, countries should build in methods to regularly
performance and develop their strategic directions with the required investments
for program sustainability and also invest in capacity building;
- A significant proportion of national immunisation 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 immunisation
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.
1: period of latest national comprehensive EPI program review by
country; Eastern and Southern Africa subregion (2012-2018)
summary of findings on Vaccine Management and Cold Chain systems
Table 3: summary of findings on Immunisation Service Delivery
summary of findings on Immunisation Monitoring Systems
summary of findings on Vaccine Preventable Diseases Surveillance
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