Drivers of “What Works” for Strengthening Routine Immunization in Africa

Objectives and background: 

In Africa, immunization coverage has improved from DTP3 coverage of 55% in 2000 to 77% in 2010, but evidence on how this has been accomplished is limited.  The Africa Routine Immunization System Essentials project, supported by the Bill & Melinda Gates Foundation, was mandated to improve the understanding of the drivers of improved routine immunization performance in Africa.

Methods and Results

In-depth case studies were carried out in 12 districts in three countries (Cameroon, Ethiopia, Ghana) that had increased and sustained DTP3 coverage in the past decade.  Study districts had at least 65-70% DTP3 coverage over the past three years, recent increases in DPT3 coverage, and over 80% DPT3 coverage in 2009.  For comparison, a “steady” district in each country with similar baseline data in 2007 but unchanged performance was also studied.  An assets-based, qualitative methodology was used, supplemented with selected quantitative analyses.  Studies examined district-level drivers of change and their interaction with the immunization system and the broader context.  

Comparative analysis across 12 districts identified six common drivers of immunization performance.  Some entailed program-specific actions, i.e., active, frequent performance review processes.  Others pertained to broad health system improvements to strengthen the link between health services and communities.  Active community involvement and strong district management emerged as cross-cutting themes essential to moving immunization programs from good to very good levels of performance.

Conclusions

While the drivers operate upon a basic foundation of a functioning immunization program (vaccines, cold chain, trained personnel), the prominence of community-oriented drivers suggests an area of focus for immunization programs in reaching the hard to reach and improving equity. Features of the broad health system (human resources reform, decentralization) have the potential to drive immunization performance, if applied strategically. These drivers are related and build upon each other to improve coverage.