Exploring Barriers to Immunization Coverage within a Sub-Saharan African Setting

Background In 2015, world leaders adopted 17 global goals (Sustainable Development Goal, SDG), committing their nations to eliminate poverty and human sufferings, protect the planet and enable all people, “irrespective of who they are and where they live”, to enjoy peace and prosperity by 2030. The third goal (Goal #3) was designed to promote “good health and wellbeing” and the same leaders committed their nations to prioritize those who are further behind, including those residing in communities that are beyond the reach of conventional healthcare systems. Under the third goal, they pledged to put an end to preventable deaths among newborns and children, by committing to reduce neonatal and under-5 deaths to below 12 per 1,000 and 25 per 1,00 live births, respectively. To date, vaccines are undisputable tools that world leaders can leverage to help their countries reduce child mortality. While many countries have made great progress toward global immunization targets, others, particularly those in sub-Saharan African, are largely off-tract to achieving the targets defined by the global health community. Indeed, each year, many Expanded Program on immunization (EPI) fail to fully immunize 20 million children with basic pediatric vaccines. The systems also fail to reach 13 million children with a single immunization shot. This failure has led to an uneven distribution of the benefits of vaccination across and within many countries. In Cameroon, for instance, progress to reach these global targets have not only stalled but is slipping backwards. Indeed, coverage for the third dose of diphtheria, pertussis and tetanus containing vaccine (DTP-3) has progressively declined, falling from 89% in 2013 to 79% in 2019. Similarly, the proportion of districts with a DTP-3 coverage of at least 80% has plummeted, declining from 88,69% in 2013 to 50,53% in 20193. This negative trend extends to all other antigens in the country’s immunization schedule, including BGC, Rotavirus, Pneumococcal and Measles combined vaccines. DocuSign Envelope ID: 08209D5A-247D-4869-A7D0-7264C2672786 PHD THESIS IN LIFE SCIENCES 07/08/2023 17 Recognizing this challenge, the government of Cameroon has engaged several efforts to stop and reserve the negative trend. These including upgrading the country’s vaccine cold chain infrastructure, developing and executing capacity building plans for EPI personnel; putting in place policies and strategies to improve immunization service delivery at facility level; improving data systems and programmatic and financial management capacities at central and regional levels- amongst others; however, despite these colossal investments from the state and its development partners, immunization coverage and equity continue to decline, suggesting that they may be other factors accounting for the declining performance. In this thesis project, the author hypothesizes that four key factors, which have not been previously studied may represent the underlying reasons for the declining performance. These include: 1. The inability of Cameroon’s EPI to equitably reach all eligible vaccination targets. 2. Disruption of immunization by the COVID-19 pandemic. 3. The ongoing armed conflict in two of the country’s regions, which has disrupted supply chains, caused facilities to be shot down and personnel to flee from their duty stations. 4. Frequent stockouts of vaccines, resulting from unknown financing and procurement bottlenecks: Aims and objectives The overall goal of my thesis project is to explore barriers to optimal immunization coverage and equity in Cameroon and to leverage the findings to develop scalable strategies and interventions that can be used to improve coverage not only in Cameroon but also in similar settings in Sub-Saharan Africa. To attain this goal, I defined five specific objectives for the project namely: 1. To identify and characterize “hard-to-reach” populations or Zero-Dose Children (ZDC), Under-immunized children (UIC) and missed communities (MC) in Cameroon. 2. To assess the impact of the COVID-19 pandemic on vaccination coverage in Cameroon. DocuSign Envelope ID: 08209D5A-247D-4869-A7D0-7264C2672786 PHD THESIS IN LIFE SCIENCES 07/08/2023 18 3. To assess the effect of the ongoing armed conflict in the Northwest (NW) and Southwest (SW) regions on key immunization indicators, including the Bacillus Calmette–Guérin vaccine (BCG), the third dose of Diphtheria-Tetanus and Pertussis, containing vaccine (DPT-3) and Measles-Rubella combined vaccine (MR). 4. To assess the procurement and financing processes for EPI vaccines in Cameroon 5. To develop and test a package of scalable interventions for each of the above specific objectives for addressing barriers to optimal immunization coverage and equity in Cameroon and other SSA settings. Methods To accomplish the above objectives, I conducted a cross sectional study operational research study, which utilized both quantitative and qualitative approaches. For specific objective #1, I used a quantitative approach, which involved data triangulation of 8 principal data sources, as well as QGIS technology to produce maps of underserved communities in Cameroon. In addition, I use a qualitative approach to explore supply and demand side barriers to reach ZDC, UIC and missed communities (MC) with immunization services. To accomplish objectives #2, #3, I used a quantitative approach to assess the effect of COVID-19 and civile strife on key Routine Immunization (RI) indicators in two target regions. For specific objective #4, I used both qualitative and quantitative approaches to explore bottlenecks impacting sustainable procurement and financing of vaccines in Cameroon. To accomplish specific objective #5, we implemented three pilots, with baseline and an endline assessments. The approach we used to accomplish these objectives is described in the section below. Results and conclusions In this thesis project, I sought out to assess barriers to optimal immunization coverage and equity in Cameroon and to leverage the findings to develop scalable strategies and interventions that can be used to improve coverage not only in Cameroon but also in similar settings in SSA. The first identified DocuSign Envelope ID: 08209D5A-247D-4869-A7D0-7264C2672786 PHD THESIS IN LIFE SCIENCES 07/08/2023 19 barrier is the inability of the current healthcare system to reach ZDC, residing in MC with immunization services. Currently, there are several of these MC in Cameroon, with high numbers of ZDC and UIC. These MC are heavily concentrated in the EN, LT, SW, and OU regions; however, there are several pockets of such communities across the entire country. Overall, Cameroon seemingly has nearly 130,000 ZDC and over 180,000 under immunized children, representing 14% and 19% of the 2021 birth cohort (943,116), respectively. This finding lends supported to that reported by Chard and collaborators that Cameroon is amongst the top 10 countries, accounting for 86% of the 7.3 million ZDC in the world1 . Guided by this finding, and in the context of limited resources, Cameroon and her development partners should prioritize reaching ZDC and UIC in 42 districts across the country. This prioritization may enable the country to immunize over 50% of these ZDC and UIC. I also went further to propose a model that could be leveraged to deliver immunization services to the identified MC. This model This model was leveraged to immunized over 8,500 ZDC in 20 missed communities2 . In future, I plan to guide other researchers and students to evaluate the cost-effectiveness of the model. The second important factor is the unparallel effect of COVID-19 pandemic on key immunization indicators in Cameroon. The pandemic caused the number of ZDC to rise by roughly 10% between 2020 and 2021. Furthermore, the pandemic disrupted key immunization indicators in 3,669 surveyed facilities. Indeed, access in these facilities dropped by 42%, utilization by 40%, total number of fixed sessions by 33% and outreaches by 19%. Similar trends were observed at health area and district levels. The findings also suggested that nearly half of all districts and health areas witnessed an increase in the number ZDC. Next, the ongoing armed conflict in the NW and SW regions of the country has also impacted key immunization indicators in the regions. Findings from the project suggest that coverage rates plummeted considerably during the study period, with declines for almost all antigens ranging between 20 and 41% during the study period (2016 and 2019). Further, about 3 in 4 districts registered DocuSign Envelope ID: 08209D5A-247D-4869-A7D0-7264C2672786 PHD THESIS IN LIFE SCIENCES 07/08/2023 20 coverage rates below 40%, with almost two-fifth (39%) of them having a coverage of below 20%. The project also noted a dramatic decline in the number of facilities offering immunization services in both regions during the study period, which had a profound impact on coverage at national level. Indeed, national coverage for DPT-3 dropped by 9%, falling from 84% in 2016 to 75% in 2019. In the same vein, the percentage of districts with a DPT-3 coverage of at least 80% dropped by 15%, falling from 60% in 2016 to 45% in 2019. To protect vulnerable populations from VPD in these two regions of Cameroon, proven strategies for delivering RI services would need to be implemented. This later assumption was piloted during this project. Finally, the not so obvious procurement and financing bottlenecks are important barriers, with a far reaching consequence on vaccine availability and adequacy. The process appears to be complex, lengthy and involves several stakeholders, who do not necessarily talk to each other. This disconnect ultimately affects funding allocation and mobilization for the procurement of vaccines. Indeed, funding allocated for vaccine procurement during the study period ranged from US$2.6M to US$6.2M, which is grossly insufficient to meet the evolving vaccine needs, that must cater for an ever-expanding birth cohort and new vaccine introductions. Mobilization of allocated funds was also an uphill task, taking an average of 11 months. This lengthy time made the country to fail to meet its vaccine funding requirements. Indeed, the government failed to purchase all the vaccines required between 2016 and 2019 due to inadequate funding and delayed disbursement. During the same period, a US$4-million funding deficit prevented the government from purchasing vaccines on time, leading to stockouts at service delivery points. During this period, Cameroon spent US$4M less than the forecasted need, impeding the procurement of 20 million doses of vaccines, causing spikes of stockouts for both traditional and co-financed vaccines, which in turn contributed to a decline in vaccination coverage and equity. Three systemic factors accounted for these observations, namely: 1) weaknesses in forecasting, 2) inefficient processes in allocating funds, and 3) delays in mobilizing the allocated funds. Suggested actions to redress these included: DocuSign Envelope ID: 08209D5A-247D-4869-A7D0-7264C2672786 PHD THESIS IN LIFE SCIENCES 07/08/2023 21 • Establish a technical working group for vaccine financing & procurement to ensure regular, rapid, adequate & sustainable supply of vaccines. The group should be composed of members drawn from the bodies, involved in the vaccine procurement function of the government, including a representative from the Ministries of Finance, Health, Economy, Central Treasure, WHO, Unicef, Gavi and CHAI. The group reports to the minister of Health and meets biannually. The meetings are currently funded by CHAI and will eventually be funded by Gavi and transitioned to the state. The group has already registered remarkable progress including ensuring timely mobilization disbursement of funds for vaccine procurement 2022 and in 2023, the country is on track to meeting all is co-financing requirements. • Appointment of a Focal Point at the EPI to monitor government commitments & lead advocacy for more efficient processes and timely disbursement of funds. • Set-up a disbursement plan to split the amounts requested by the EPI into five installments for easier approval and disbursement. Finally, three set of interventions can be deployed to improve RI coverage and equity in Cameroon. These include leveraging on existing data sources to identify and characterize hard-to-reach communities and harnessing the information to design context specific strategies that can be used to deliver immunization services to identified MC. Second, leverage periodic intensified routine immunization strategy (PIRIs) to raise coverage in crises zones. Third, establish a TWG to improve the procurement and financing processes for vaccines. DocuSign Envelope ID: 08209D5A-247D-4869-A7D0-7264C2672786 PHD THESIS IN LIFE SCIENCES 07/08/2023 22 Recommendations Basing on our objectives and findings, we recommend governments and other stakeholders that aim at improving immunization coverage and equity in any facility, administrative, health area, district, regional and national level to considered implementing the following recommendations. 1. To reach ZDC, UIC and missed communities, we recommend the target audience to: 1.1.Use data analytics, leveraging various existing data sources to identify the distribution of ZDC, UIC and missed communities at health area, district, regional and national levels. 1.2. Leverage Human Centered, qualitative and systematic or document reviews to explored both demand and supply barriers on why these children miss out on basic primary healthcare services, including vaccination. 1.3.Leverage the information emanating from 1.1 and 1.2 to develop- context specific strategies to reach these children in their respective settings be it in crisis zone, remote enclaved zones, urban slums, or fluvial communities. 1.4. Mobilize resources through targeted advocacy 1.5.Pilot interventions in selected settings, document successes and failures and leverage these to prepare scaleup plans. This recommendation has been used by the EPI to apply for funding from the Gavi Equity Accelerator fund to improve vaccination coverage and equity in MC. Outcome of the application is expected in September 2023. 1.6.Engage the government to develop a national policy on reaching the unreached coordinate with them to create a budget line for this as well as engage their development partners, multilateral and bilateral donors to support them in the implementation of the policy. 2. To mitigate impact of a public health emergency on key health indicator we recommend interested stakeholders to: 2.1.Use basic resources to develop analytical tools that could be used to measure and track impact of the emergency on key health indicators. 2.2. Leverage the tool to capture data from existing data sources to create analytics that could be used for quick decision making, guide actions and monitor progress. DocuSign Envelope ID: 08209D5A-247D-4869-A7D0-7264C2672786 PHD THESIS IN LIFE SCIENCES 07/08/2023 23 2.3.Support governments to develop recovery plans, highlighting areas that should be targeted for catch ups and well as the strategies to use. 3. To improve RI coverage in conflict zones, we recommend governments to: 3.1.Leverage existing data to study trends to establish impact of the crises on key health indicators, including immunization. 3.2.Develop context specific strategies on how to reach target populations in these areas with health interventions Leverage existing local resources (including trusted people in the community, local transportation means etc.) to get the necessary logistics to the target sites. 3.3.Collaborate with the local stakeholders to rollout campaigns, such as PIRIs and target reaching the maximum of the target population, including internally displaced persons and refugees. 3.4.Set up data systems to capture and transmit data, emanating from the campaigns. 4. To mitigate the impact of sub-funding fund allocation and mobilization for the procurement of vaccines or other health commodities, we recommend the state to: 4.1.Map its current procurement and financing processes to gain insights into the various pain points and bottlenecks. 4.2.Assess impact of key bottlenecks on key health indicators, such as vaccine stockouts and their association of coverage and disease outbreaks 4.3.Establish a multi-sectorial technical working group with clear terms of reference and provide them with the necessary resources to perform their duties. 4.4.Use data to conduct accurate forecasting of vaccine needs and translate that into dollar amount. 4.5.Establish a disbursement plan, which splits the amounts to paid into small installments for easy approvals, mobilization, and disbursements. 4.6.Establish a monitoring and evaluation system, which will enable the tracking of key performance indicators, document lessons-be them positive or negative-, put in place plans to mitigate risks and implement corrective actions when problems arise.