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June 2009 | Issue 9

SnapShots is designed to keep busy public health professionals abreast of developments in the immunization world. Each issue focuses on an important topic or topics that may affect USAID missions, projects and country partners. We welcome your comments and suggestions.

Working with Communities to Strengthen Immunization

The Topic

The "public" in public health implies an important link between people and health systems. Community involvement is critical to the success of immunization. This issue of SnapShots describes some practical ways to build alliances between communities and health services to improve immunization coverage.

Why is this topic important?

Immunization currently prevents over two million child deaths each year. Strong immunization systems are increasingly important to sustain past immunization gains and ensure that new, more expensive vaccines, which have the potential to save several million more lives each year, are smoothly introduced. Community participation in immunization programs results in higher coverage and reduces the incidence of vaccine-preventable diseases. Informed and involved communities strengthen immunization programs by holding governments accountable to provide or increase support for immunization services. Communities can assist in planning, carrying out, and monitoring regular immunization and other primary health care services.

Download Training for Mid-Level Manager's Module (MLM): Partnering with Communities.

NEWLY AVAILABLE!
WHO Mid-Level Managers Module,
Partnering with Communities

This new training module from WHO describes how mid-level immunization managers can work more effectively with the communities they serve and how communities can help in managing immunization services.

Intended for use by immunization program managers, health workers and NGO partners, the module has chapters on planning with the community, implementing and monitoring immunization services with community involvement, effective communication for community involvement, and tools and channels for communicating information on immunization.

Users may find the annexes helpful, as well. They include suggestions for NGO involvement in immunization, tips for group discussions in the community, common questions about immunization from the public and suggested answers, the information that health workers should give all caregivers, and other materials for education and promotion in the community. The module is also interspersed with learning activities to facilitate its use in training, and there is a companion facilitator’s guide.

Recognizing the role of the community

Several international initiatives and strategies have already recognized the important role that communities play in improving both immunization programs and other primary health care services:

  • The WHO/UNICEF Global Immunization Vision and Strategy (GIVS) includes a sub-strategy for increasing community demand for immunization and notes that "community mobilization provides an entry point for the alleviation of system-wide barriers;"
  • Worldwide, countries and partners are implementing the Reaching Every District (RED) strategy. "Community links with service delivery" is one of the five RED components; and
  • Also, the GAVI Alliance has recently begun to offer support to increase the involvement of civil society organizations (CSOs) in immunization and other essential child health services.

This high-profile attention has fueled interest in techniques for partnering with communities to improve not only immunization but also primary health care services, in general.

"Sharing responsibilities" instead of "increasing demand"

The purpose of community participation in immunization programs is often described as "increasing demand." This is misleading because it gives the impression that a lack of motivation or desire for immunization is the reason why children are not being vaccinated. Studies in many settings show that families are very willing to have their children vaccinated if:

  • services are available at a convenient time and place;
  • they know how to access these services; and
  • the services are of good quality.

The community component of RED

Since 2002, WHO and partners have supported the RED (Reaching Every District) approach to improving immunization coverage. Evaluations of RED in 2005 and 2007 in the Africa Region showed that districts implementing the approach were raising immunization coverage and that the approach could be used to integrate additional interventions. The 2007 evaluation also found that many health facilities were including community mobilization, meetings with community leaders and frequent interactions with community volunteers in their work plans and regular activities. The 2007 evaluation also confirmed that community volunteers were commonly involved in providing health education, assisting during outreach sessions and tracking immunization defaulters. Fewer than half of all community volunteers, however, were registering pregnant mothers and births, and volunteers were not sufficiently involved in planning immunization sessions and/or reporting diseases. The authors concluded that: "active involvement of community volunteers [is] key in increasing immunization demand, particularly for outreach in rural areas." (View a copy of the 2007 RED evaluation.)

Graph showing Percent of HFs with community volunteer support for activities: Education and mobilization 84%, Assistance during outreach 62%, Defaulter tracking 59%, Involvement in planning 47%, Reporting of disease cases 46%, Providing resources 36%, Registration of pregnant women / newborns 33%, Other 7%

Steps for involving communities in routine immunization

Health planners and managers should first assess the extent of community involvement in planning, providing, and monitoring their health services. Who are the community health leaders? What types of community-based organizations are already engaged in or could be engaged in health promotion? Are there community health or development volunteers playing a role in immunization and other primary health care services? Who are they? Where are they? Could their role be enhanced?

Although health staff may not be able to radically change service-delivery schedules, they should be willing to move toward immunization schedules that work for all involved. By consulting with community representatives in meetings, interviews, and group discussions, they will learn about community preferences and availability. By asking for community input over time, they will learn—from the clients' perspective—how well they are communicating key information, inviting and responding to questions, and treating families. If health workers give regular feedback to communities about coverage and disease outbreaks, community members will also be able to help in identifying underlying problems and defining practical solutions.

What can health workers, communities and USAID missions do?

Failing to partner with communities for immunization and other health activities is a missed opportunity. The new WHO Mid-Level Managers Module, Partnering with Communities (see page 1), suggests many practical ways to involve community leaders and community-based groups in immunization. We summarize some of these in the Quick Reference below and add some suggestions for USAID Missions and projects, as well.

Quick Reference: Linking Communities and Health Facilities

What can communities do to help improve immunization and other PHC services?

Community members can assist with implementation by:

  • cleaning and organizing outreach sites (such as schools and community meeting rooms);
  • informing families of scheduled outreach and when the health worker has actually arrived;
  • registering patients, controlling crowds, and making waiting areas more comfortable (by providing shade and organizing space and seating);
  • disseminating appropriate messages and answering questions (health education);
  • motivating fellow community members to use immunization and other PHC services;
  • transporting vaccines; and
  • making home visits for children who are behind schedule to explain immunization and motivate caregivers.
Involving communities in the planning of primary health care services can lead to higher turnout on scheduled immunization days, and healthier children as a result. Photo credit: IMMUNIZATIONbasics, Nigeria

Community leaders and mobilizers can make important contributions to monitoring by:

  • helping to track the immunization status of infants and ensure that each of them is fully immunized by 12 months of age (for a practical monitoring tool, see "My Village is My Home"); and
  • giving feedback to health managers on the reliability and quality of immunization (and other) services.

What can mid-level managers do to encourage community participation in immunization?

  • Use district coverage, drop-out, and micro-planning data to determine the reasons for inadequate coverage;
  • Analyze the quality of communication approaches and activities to support each of the five components of the Reaching Every District (RED) strategy. View a copy of the WHO/AFRO 2008 RED guide at: http://www.immunizationbasics.jsi.com/Docs/AFRO-RED-Guide_2008_FINAL.pdf;
  • Review, revise and monitor community and communication strategies using indicators within the reporting and tracking system for immunization. Include communities in supervision and reporting. For suggested indicators, see pages 14-15 of the BASICS II/USAID "Strengthening Immunization Programmes: The Communication Component" guide;
  • Involve NGOs and community leaders/groups at the district level in coordination meetings to share tools, guidelines, and program achievements and obstacles;
  • Monitor community contributions to improving services at the district level. This could include mechanisms like "memoranda of understanding" with communities and NGOs to outline collaboration as well as reporting on community involvement as part of quarterly and annual reports;
  • Inform key leaders (such as religious and community leaders) about the danger of vaccine-preventable diseases, the availability of immunization services, and the status of coverage and other indicators in order to gain their cooperation and support; and
  • Train health workers and community educators to strengthen their interpersonal communication skills, to give correct information, and to motivate them to improve service delivery.

What can USAID-funded projects and USAID missions do?

Public health interventions like immunization are too valuable and effective to be the responsibility of health staff alone! Funders, planners, and implementers need to take advantage of the multiple opportunities to improve immunization and health programs by promoting increased community involvement.

  • USAID and its health program managers can participate in inter-agency coordination committees (ICCs) and advocate for community involvement in all health programs;
  • They can also encourage CSO or NGO partners to take advantage of newly available GAVI support for immunization and health system strengthening; and
  • Moreover, projects funded by USAID can encourage government and NGO counterparts to involve communities more intensively in immunization and provide resources and tools to assist them.

Resources

Additional documentation and tools are also available in the "Resources" section of the IMMUNIZATIONbasics web site.

Please send any requests or questions regarding SnapShots to ImmBasics_Info@jsi.com.

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This publication was made possible through support provided by the Office of Health, Infectious Disease and Nutrition, Bureau for Global Health, U.S. Agency for International Development, under the terms of Award No. GHS-A-00-04-00004-00. The IMMUNIZATIONbasics project is managed by JSI Research & Training, Inc., and includes Abt Associates, Inc., the Academy for Educational Development, and The Manoff Group, Inc., as partners. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development.