Mainstreaming demand for immunisation

We were contracted by the UNICEF Regional Office for Europe and Central Asia (ECA) to conduct an assessment of interventions for the generation of demand for vaccines in four countries - Armenia, Georgia, Moldova, and the Kyrgyz Republic – that are increasingly facing vaccine hesitancy, further compounded during Covid-19.

The first part of the study comprehensively looked at interventions aimed at increasing vaccine uptake in these countries. Five broad areas of interventions suggested by GAVI the Vaccine alliance, were covered:

a) building social and political will;

b) engaging communities and shaping social norms;

c) managing risks and building resilience;

d) enhancing service quality and accountability; and

e) harnessing social data for learning, planning and decision making.

We looked at existing interventions- whether these were ad hoc or followed a regular plan, were designed in a targeted manner to address local gaps, and if they had a system for regular monitoring and evaluation. We also explored the extent to which they were systemically integrated in a government’s immunisation programme, if they were allocated domestic budget and if they were implemented through government structures with competent, adequately trained government staff (as opposed to international or non-governmental financial and human resource help).

The second part of the study involved making country specific actionable recommendations to incorporate interventions towards increasing vaccine uptake, into government policies, structures and budgets. This was undertaken so that mainstreaming of generation of demand is given the required priority in immunisation programmes of countries– which often focus on aspects related to supply.

Challenges

The Situation Assessment showed that all four countries have a National Immunisation Programme (NIP) and do implement (albeit ad hoc) a range of interventions for generating demand for immunisation.

Armenia, however, does not have a formalised demand generation component/strategy within its immunisation programme. Although this exists for the Kyrgyz Republic and Georgia, it is conceived narrowly, focussing on traditional approaches like information, education and communication (IEC).

Some challenges identified in the assessment were:


a) increase in vaccine hesitancy due to various reasons: pressure exerted by religious groups, personal contacts, and family and community members through traditional and social media, as well as negative experiences with the health system and health workers, and adverse effects following vaccination;

b) the need for an overall comprehensive integrated strategy for increasing vaccine uptake, with a plan for regular systematic, well targeted  activities  including  adequate monitoring;

c) gaps in capacity of national stakeholders at national and sub-national levels to develop, implement and monitor demand generation interventions, requiring an upgrading of skills beyond IEC;

d) dependence on external partners (e.g. GAVI, UNICEF and WHO) to fund  demand generation activities, a low-priority item in domestic budgets, that only factor in base salaries of personnel involved.

Our approach

We conducted a desk review of relevant documents, and interviewed individuals as well as groups of  decisions makers and representatives from national agencies and international partners involved in the planning, implementation, and M&E of the National Immunisation Programme of these countries.  Further, those involved in demand generation activities (general as well as related to immunisation) were also interviewed. The findings related to existing interventions and the extent to which they were mainstreamed were then discussed at a validation workshop. Recommendations were then developed based on these discussions and a review  of  replicable ‘good practices’ for sustainable demand generation, in other countries in the ECA region and globally, was done. Most of the work had to be undertaken online given COVID-19 related restrictions.

We were guided by the GAVI criteria for assessing the extent to which existing interventions could be judged as being mainstreamed based on the extent of:

a) policy and budget integration,

b) availability and allocation of domestic human and financial resources,

c) adequacy of organisation structures with relevant expertise and capacity,

d) prioritising, targeting and tailoring of demand generation interventions to reach under immunised communities, and

e) effective monitoring and evaluation to allow assessment of progress and course corrections.

Based on the assessment, interventions were classified as being partially or fully mainstreamed for each criterion - with the fulfilment of three criteria (a, b and e, i.e. related to the budget, organisational structures, and the M&E framework) being considered mandatory for classification of interventions as being fully mainstreamed.

Outcomes

The findings were detailed in the form of four initial analytical reports (and presentations) on the existing situation about the status of mainstreaming of interventions for demand generation in the project countries. A second set of reports contained recommendations on the main entry points, and suggested actions within each of these towards increasing mainstreaming of existing as well as new evidence-based interventions for increasing demand towards vaccination.  Recommendations include  action on multiple fronts in line with GAVI.  Mainstreaming generation of demand requires firstly the development of a comprehensive strategy which forms part of the national policy framework. Further required are improved planning and coordination between structures/departments in place dealing with the generation of demand for immunisation at national and sub-national levels; allocation of dedicated assured funding by government; the need for adequate health staff with the required specialist skills and training identifying and directing specific efforts towards under immunised communities (rather than having a standard uniform approach) and structures in the country to  monitor progress and feedback to allow for course corrections.   

Given the Covid-19 pandemic, the importance of increasing vaccine uptake has been brought to the forefront. Taking advantage of this ‘policy window’, these recommendations were presented to national policy makers and implementers as well as staff from international organisations within each of the four countries for their feedback. It is expected that with support from UNICEF, these actionable recommendations will translate into changes within the immunisation framework in Armenia, Georgia, the Kyrgyz Republic, and Moldova, contributing to the development of mainstreamed, systematic and sustained approaches to increasing vaccine uptake.

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