As the world gradually recovers from the COVID-19 pandemic, the Government of Guinea has intensified its efforts to improve the availability of immunization services in the country's health facilities and optimize the performance of the national immunization program. The government has worked with partners to address issues related to leadership and governance, financing, supply chain and logistics systems for vaccines and other consumables, data management, and capacity of health care providers and managers.
However, performance on several indicators related to maternal and child health still remains weak. According to data from the 2012 and 2018 DHS surveys, the proportion of pregnant women who went to prenatal consultations fell from 57% in 2012 to 37% in 2018. Similarly, the proportion of fully immunized children decreased from 36.5% in 2012 to 29.6% in 2018.
Revitalize the routine immunization system
As a result, cases of circulating vaccine-derived polio have been recorded in the Kankan region (1 case in 2014, 7 cases in 2015), as well as the occurrence of measles epidemics with more than a thousand cases each year. More recently, in 2021, the Kankan region recorded nearly 26,406 zero-dose children (not vaccinated with Penta 1).
To address these challenges, the Bill & Melinda Gates Foundation is supporting the Government of Guinea on the basis of a Memorandum of Understanding (MOU) between the two parties to revitalize the country's routine immunization system as an entry point to strengthening the overall health system. Since the signing of the MOU in 2021 and the launch of the Routine Immunization Strengthening Program (RISP) in April 2022, various interventions have been put in place to address specific gaps in the immunization system.
Strengthen community engagement
The Foundation, through its implementing partner, Askaan, has worked side by side with governments at the central and local levels to strengthen community engagement and participation in the planning and delivery of immunization sessions. Indeed, in order to achieve high immunization coverage rates, it is essential that there be a strong demand for routine immunization services so that every eligible child in the community is fully immunized and protected against vaccine-preventable diseases.
These efforts were concentrated in the Kankan region, which was chosen as the pilot region for a number of reasons. First, it is the most populous region with the largest area. Second, as a major mining region, Kankan is home to a large vulnerable (migrant) population with a large influx of people across borders and continuous movement within communities; posing unique challenges for monitoring and immunizing eligible children.
Map the main influencers
In order to design the right demand optimization strategy, it was important to map the key influencers within the community that determine whether or not a child is vaccinated.
A quick analysis of the context of the Kankan region showed that there are five levels of influence across communities as follows
1. The primary and immediate level of influence includes mothers and caregivers who are often responsible for taking the child to the health facility for immunization; and fathers who make the decision, authorizing the child's immunization and paying for it.
2. The secondary level of influence primarily includes stepmothers who have mothering experience and provide guidance to the child's mother from pregnancy through delivery and infancy.
3. The tertiary level of influence includes community stakeholders outside the immediate family. These include religious leaders, community health workers, community relays, town criers, traditional healers and community media leaders.
4. The next level of influence includes the health and hygiene committee that is present in each commune. This committee is composed of the mayor, the head of the commune's health center, and representatives of women, youth, civil society organizations, and other key community members.
5. The last level of influence is composed of individuals outside the community such as the regional governor, the prefects and sub-prefects supervising the district, and the head of religious affairs at the regional and district levels.
How to stimulate demand improvement?
A situational analysis of the reasons forthe low demand for immunization services in the Kankan region revealed a number of obstacles. These include lack of knowledge of the immunization schedule, confusion between routine immunization and immunization campaigns, lack of trust in health workers and fear of their reaction following a missed appointment, fear of side effects, poor reception in health facilities, misconduct of some health workers towards clients, lack of a clear system for communicating immunization messages via the mass media, among others.
Based on these results, the overall goal was clear: to strengthen community participation and involvement in the planning and delivery of immunization and broader health services, building on existing community structures. The specific objectives were to:
- Increase community participation in the development and implementation of plans for immunization and broader health services
- Systematically identify children eligible for immunization in the community and link these children to the health system
- Regularly and systematically track abandoned and zero-dose and lost children and reduce missed opportunities for immunization
To achieve these objectives, a series of interventions were designed and implemented with a focus on strengthening existing systems in a sustainable manner. These included the organization of reconciliation meetings between health workers and community relays.
Over 621 reconciliation meetings held
Indeed, in order to establish a transparent communication system between the health system and the community at the lowest levels, the reconciliation meeting approach was introduced, guaranteeing a monthly meeting bringing together the different actors involved: the center chief, the EPI agent, the ANC agent, the heads of the posts and the community agents reporting to the health center. Thus, the health agent sits down with each community Relais to compare the immunization register of the children of the health facility that he/she holds with the list of eligible children of the community Relais.
During this meeting, the health worker reviews the list of newborns and entrants in the previous month, and compares this information with the child immunization record to verify that all have been seen either at the health facility (fixed strategy) or during advanced strategies for routine immunization.
The second part of the meeting between the health worker and the community outreach worker focuses on identifying children who have missed their immunization appointments and/or have been lost to follow-up. A key deliverable is a list of children who need to be found in the community to understand the reasons why they did not come to their immunization appointments and mobilize them for immunization if necessary.
At the end of the meeting, both parties are able to agree on a list of children who should be actively sought. From this list, the community health worker can identify them, encourage them to be vaccinated at the nearest health facility (health center or post) and follow up on the effectiveness of the child's vaccination.
Thousands of children found and vaccinated
Since the start of the activities, all the health centers have organized their monthly reconciliation meeting to identify irregular and lost patients. In terms of results:
In terms of results:
- 100% of the health facilities have community registers and a lost persons' booklet
- Out of 31,519 children lost to follow-up, 26,160 children were found and vaccinated in the 5 districts, i.e. a performance of 83%.
- The DPSs of Kankan, Siguiri and Mandiana have the largest number of children to catch up with, with a peak in Kankan (18,584 children to catch up with)
- More than 80% of children were found and vaccinated in 4 out of 5 districts (79% in the district of Kouroussa)
- Strong reduction in the dropout rate from 9.4% to 1.4% between the first quarter and the third quarter of 2022, which could be attributed to the reconciliation meetings and the search for the children
- Before the start of the program activities, 44 health centers were in categories[1] 3 and 4 and during the implementation, 53 health centers out of 69 are in categories 1 and 2
- 63% reduction in the number of zero-dose children in the Kankan region between 2021 and 2022
An innovative approach to community engagement
The implementation of this approach has allowed us to identify some lessons learned:
- The implementation of the reconciliation meetings and the search for irregular and lost children has helped to catch up children and reduce dropout rates.
- Untimely shortages of vaccines and consumables are a permanent threat to the sustainability of the program because they slow down efforts to continuously optimize vaccine coverage;
- The implementation of the supply plan has improved the availability of vaccines and consumables
- Analysis of the organization of advanced strategies should be a systematic practice to significantly improve efficiency in implementation
- Child tracing should not be an isolated activity, but should be integrated into the health center's service package.
- After analysis of the reports on the search for lost persons, the mother's failure to keep the appointment was one of the main reasons given, followed by the lack of transportation to the health facility
- It would be useful to set up a system for reminding women or any other person in the household who can make the reminder of vaccination appointments (head of household, adolescent, etc.).
- The low level of education of mothers is also an obstacle to keeping vaccination appointments
In conclusion, optimizing the demand for and use of immunization services requires synergy between community actors and health systems. The community plays an important role in health promotion and should not be sidelined in the development of interventions to improve the use of immunization services. The deployment of innovative strategies to identify children eligible for immunization, to compare community registers with health facility immunization registers, and to identify and track lost children has reduced dropout rates.
Although challenges remain, this approach has demonstrated that with greater community involvement and participation, demand for routine immunization services can be improved. In addition, lessons learned from successes and failures will inform a demand generation intervention with sustainable results and benefits.
[1] Catégorie 1 : CV Penta1>=90% et Taux d’abandon<=10%.
Category 2: Penta1 CV>=90% and Dropout rate >10%.
Catégorie 3 : CV Penta1<90% et Taux d’abandon <=10%.
Catégorie 4 : CV Penta1<90% et Taux d’abandon >10%.
