Immunisation in Sub-Saharan Africa - Recommendations - Mozambique

from the report "Communication for Routine Immunisation and Polio Eradication: A Synopsis of Five Sub-Saharan Country Case Studies"

In October and November 1999, a series of case studies were carried out in five sub-Saharan countries. The broad objectives were to: document communication activities for polio eradication, routine immunisation and surveillance; exchange effective and innovative experiences; and provide recommendations for the improvement of communication interventions. The initiative was a collaborative effort undertaken by the Ministries of Health of visited countries, the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the Unites States Agency for International Development (USAID) and its subcontractors (BASICS, CHANGE and JHU-PCS). Visited countries were the Democratic Republic of the Congo (DRC), Mali, Mozambique, Nigeria and Zambia.

Recommendations:

Programme needs for more effective social mobilisation and communication support to EPI.

As mentioned in the previous page, despite the very effective, creative and enthusiastic mobilisation achieved for recent NIDs, communication activities in support of routine immunization and surveillance need significant strengthening. Many needed actions fall in two categories: (1) institutional strengthening and (2) collecting and using reliable quantitative and qualitative information as the basis for solid communication planning and implementation.

Several of these needs were agreed to at a planning seminar in March 1999 of the EPI and its main partner organizations. These included:

• Better integration of RESP (the MOH's health education unit) and the EPI
• Strengthening of RESP staff capabilities to support communication for routine immunisation
• A specific budget and funding for communication support for routine immunisation and surveillance
• A national plan for social mobilization/communication support for EPI and polio eradication

The partners have already taken some initial steps to implement these recommendations. With substantial support from UNICEF, for example, a draft five-year plan for EPI communications has been prepared. Additional problems or needs identified by the study team are discussed below.

Reliable coverage data

As mentioned above, coverage levels in the NIDs and routine immunisation are overestimated, possibly by as much as 25 per cent. Three arguments for this contention are:

• coverage rates of well over 100 per cent in recent NIDs, which informants believe are due to using population figures that are too low;
• outbreaks of measles and other immunisable diseases that indicate lower-than-official coverage; and
• the fact that many informants judge services to be deteriorating at a time when coverage is officially increasing.

Thus, programme managers do not have a precise idea how many children are unreached by immunization and where they are located; how many children start but do not complete their basic series of immunisations; how many children complete the basic series but not until after their first birthday, thus exposing them to unnecessary risk. The lack of reliable data makes it difficult for the EPI to decide, for example, to what degree to emphasize extending current services (via new fixed or mobile sites) or to improve current services where they are. Which are the priority problems – low coverage, late coverage, high drop-out rates, poor access, etc.? Having a solid basis on which to prioritise problems and design strategies is essential both for service delivery and for communication activities.

There are a number of actions that the EPI might consider to remedy this problem. They are not mutually exclusive.

• Adjust census figures to realistic levels on the provincial and/or district levels for estimating coverage.
• Carry out national and/or provincial coverage surveys.
• Institute a series of internal comparisons of the number of various antigens given on all levels - national, provincial, district and facility - so that, for example, each level would do a monthly comparison of BCG immunisations with DPT3 and measles immunisations. The objective at each level would be to continually reduce the difference between the two numbers.

Higher priority for routine immunisation and surveillance Polio eradication, as well as control or eradication of other immunisable diseases, depends on more than effective campaigns. In addition, programmes must:

• achieve high routine immunisation coverage;
• create and operate an effective surveillance system with good geographical coverage; and
• mount, as needed, local mop-up immunisation.

As much as half of Mozambique's population lacks good access to fixed facilities that offer routine immunisation, and there has been virtually no communication activities to support routine EPI, other than health education talks with mothers at the beginning of each day at service points. This picture stands in stark contrast to the tremendous effort put into social mobilization for recent immunisation campaigns.

Similarly, the quality and completeness of the surveillance system for acute flaccid paralysis (AFP) (including polio) and other diseases requires substantial strengthening in health facilities, without even considering extending it to communities and supporting it with communication activities. (Rotary officials stated that they would be very pleased to support AFP surveillance but that they had never been asked.)

Clearly, now that NIDs have been successful, Mozambique's EPI needs to focus on service strengthening and demand creation in these other areas.

Adapt effective ideas and build on momentum of NIDs While they are still fresh, the EPI should taken advantage and tap into some of the good ideas and enthusiasm from NIDs to support routine activities.

It would be neither logical nor productive for the MOH and its collaborators to devote the same intensity of effort to ongoing immunisation as they devoted to the NIDs; nonetheless, there is no reason why, for example, there could not be intersectoral committees at various levels to promote immunisation and other child health services and demand for them. There is no reason why schools, private companies, churches and other partners in the NIDs could not support routine EPI and other maternal and child health (MCH) services at a lesser or more periodic level.

The beauty of a campaign is that the goal is clear and feedback on coverage achieved is immediate (and almost always positive). Routine EPI needs to devise one or two simple indicators that can also be publicly monitored. One possibility is the percentage of children who are fully immunised when they reach their first birthday. This could be estimated and publicly reported at all levels (even the facility level), possibly creating a friendly competition among facilities, districts and provinces, and stimulating problem analysis and action to improve the indicator. Focus on basic health education in addition to mobilisation From several dozen interviews conducted by the study team, one of the most striking findings is the low level of basic understanding among mothers, fathers and local leaders concerning immunisation. These same people who so actively participated in the NIDs cannot explain what a case of polio looks like. While people have the general concept that immunisations prevent diseases, they do not know what diseases. The most common answers from parents and leaders were malaria and cholera.

One mother that the study team interviewed in Sofala Province had a paralysed leg and appeared to have been a victim of polio as a child. However, despite having six years of schooling, she had no idea that she might have had polio. Her family had had her treated by traditional healers. Yet despite her lack of knowledge about the disease, she had her own child vaccinated against polio.

Such findings are of concern for several reasons. First, the lack of basic understanding brings into question the level of true demand for immunisation. Second, if Mozambique wants to build towards participatory democracy, it needs citizens who are at least minimally informed.

Parents and programme supporters do not need to know all of the details of immunisations, diseases and the cold chain. But a mother leaving an immunization session should know what diseases her child was just protected against, when the child needs to return and the possibility of side effects and what to do about them. A mother whose child just received polio drops should know what polio is. In general, this does not appear to be the case. People have been mobilised, but not educated.

Potentially, this could be done through any number of face-to-face communication activities as well as mass media. The basics of immunisation could be taught in schools, and school children could be used as mobilizers and educators in their communities. Immunisation could be featured in local festivals and other activities. These ideas and others are included in the draft EPI communication plan.

In-depth research on knowledge, attitudes and practices of mothers, health workers and other groups (fathers, local leaders other influential persons)

While people can be mobilised for a simple action such as participating in NIDs , one cannot plan more complex communication or behaviour-change activities without an in-depth understanding of audiences – their current knowledge, attitudes and practices (KAP), the feasibility of changing current KAP, barriers to change and motivators/facilitators to change. One excellent in-depth study by the Higher Institute of International Relations appears to be the only such study ever done in Mozambique (Baptista and Baleira). Clearly, more in-depth research is needed, covering the diverse populations in the country, to develop effective communication strategies, materials and actions to support demand for routine EPI. Such studies need not be extremely costly nor use huge samples, but they must be well designed to answer key questions and be done competently and in depth. The findings must be clearly presented and effectively brought into programme and communication planning. This need is also strongly noted in Mozambique's draft EPI communication plan.

Specific strategies for hard-to-convince groups

2 groups were identified as hard to convince to participate in immunisation programmes: (1) religious groups such as the followers of John Malanga and Jehovah's Witnesses and (2) some children in urban areas, both in poor families that have little contact with mass media or local leaders and in well-off families that think immunisation is something for the poor.

Although the EPI has identified and given some special attention to these groups, there has been no systematic study of the reasons for resistance and motivations and strategies for gaining participation. In addition, the EPI lacks a very precise idea of the number of families and children in these groups and therefore of the attention they merit. In-depth research with these groups, followed by strategy formulation with the participation of leaders from the groups, would be very useful. Two logical strategies to consider are trying to convince individual leaders to cooperate and using ‘positive deviants' in the groups as peer educators and mobilisers.

In addition to the hard-to-convince, of course, are also some hard-to-reach groups. Mozambique is a large country, with many sparsely populated areas. Many people live in isolated homesteads and have difficult and time-consuming journeys to reach fixed facilities or even mobile-brigade sites. Some areas of the country, for example in Buzi district, are accessible only by boat at certain times of the year because of flooding. Again, the EPI needs to gather reliable information on these groups in order to make reasonable cost-effective decisions on reaching them with services as well as demand-creation activities.

Improvements in the client orientation of immunisation services

Mobilisation and communication alone cannot achieve full immunisation of children in their first year of life. This behavioural objective is stretched out over time, requiring at least five separate visits to immunisation sites. While people may be mobilized to bring their children once or twice, if services are not minimally satisfactory, people will not return for the full series of routine immunisations.

Services in Mozambique, as in most countries, need to be more client oriented. Easily said and agreed to, this objective is not easy to implement in an environment in which health staff have poor pay, little motivation or incentive to educate clients, and may be too busy to give more attention to individual mothers and children.

Among the factors indicating a lack of client orientation were reports of:

• long waiting times;
• health staff charging for free services;
• staff giving mothers little or no essential information;
• inconvenient service hours, e.g. mobile brigades arriving at sites and leaving before mothers return from the fields; and
• unreliable services beyond the district seats due to shortages of gasoline, cold chain equipment, vaccine and per diems.

While only some of these problems are ‘communication' issues, they all affect the possibility of communication activities successfully motivating families to have their children fully immunised in the first year of life. The EPI needs to assess the prevalence of such problems, carry out in-depth research to gain a better understanding of reasons and barriers to change, and devise and implement effective strategies.