Localization to Accelerate Progress on Childhood Vaccination

“The Big Catch Up” is a global effort to boost vaccination among children following declines driven by the COVID-19 pandemic. The hope is to reach zero-dose and under-immunized children. How can localization ensure that routine vaccines reach the babies and kids who need it most? 

In this episode, we speak with Dr. Graça Matsinhe, a medical doctor and the National Immunization Technical Lead for the MOMENTUM Routine Immunization, Transformation and Equity project in Mozambique, and Hoséa Rakotoarimanana, an Immunization Officer with the MOMENTUM Country and Global Leadership project in Madagascar, about how community engagement and locally-driven approaches can help improve health for children and families. 

We discuss how a technique called ZDROP is used for identifying and responding to zero-dose communities in Madagascar, and how routine vaccine campaigns are strengthened through grassroots community engagement, which helps build trust and counter vaccine hesitancy in Mozambique.

Transcript

[Introduction] 

MOMENTUM Presents: Bringing in-depth experience and improving maternal, newborn and child health services, family planning, and reproductive health care in countries around the world; providing technical and capacity development assistance to country leaders and governments; and ensuring that mothers and babies have access to essential care in order to reach their full potential. We are MOMENTUM Country and Global Leadership, funded by the U.S. Agency for International Development. Welcome to MOMENTUM Presents. 

[Angela Pereira] 

Hello, I’m Angela Pereira, your host for MOMENTUM Presents. This season is all about localization, how shifting power and resources to communities can improve maternal, newborn and child health. Today we are talking about that power shift within the world of immunization. 

We know that vaccines are one of the best tools that we have to prevent diseases like polio, measles and others. And now, “The Big Catch Up” is underway. This is a targeted global effort to boost vaccination among children following declines driven by the COVID-19 pandemic. The hope is to reach zero-dose children, those kids who have had no vaccines at all, and under-immunized children, those who have had some routine vaccines but are missing others. 

So, I'm joined today by two distinguished guests who can share stories of their efforts to help catch up and reach zero-dose and under-immunized children with lifesaving vaccines through innovative tools and community engagement.  

So, welcome to Hoséa Rakotoarimanana, an immunization officer of the MOMENTUM Country and Global Leadership project in Madagascar. He specializes in implementing innovative approaches to improve health care delivery and vaccination programs in the country. Among these innovative approaches is the ZDROP tool, which we will hear about on today's episode.  

Next, we have Dr. Graça Matsinhe, a medical doctor with extensive experience in immunization. She is the National Immunization Technical Lead for the Momentum Routine Immunization Transformation and Equity Project in Mozambique. Previously, she directed the country's expanded program on immunization, where she helped lead the design, implementation and monitoring of immunization strategies and health policies. 

Welcome Graça and Hoséa. I'm so thrilled to have both of you here today. Why don't we start with you, Hoséa: Tell me more about “The Big Catch Up” campaign. Why is it important?  

[Hoséa Rakotoarimanana] 

Thank you so much, Angela.  We talk about “Big Catch Up” when countries like Madagascar and Mozambique present the number of zero-dose children higher than the global mean. 

So, for both Madagascar and Mozambique, we have one in three children who are zero dose. The global mean is one in five. So, what is the statistics? So, globally, we have around 15 million children who are zero dose in 2022. In the ratio, we can transform it into one in five children are zero-dose children in 2023, which is very, very critical.  

[Angela Pereira] 

So, in countries like Madagascar and Mozambique, 1 in 3 kids are considered zero dose, which is above the global average of 1 in 5. Graça, could you jump in here and explain why these children are not vaccinated? 

[Graça Matsinhe] 

Hi, Angela. Hi, Hoséa. First, let me acknowledge the invitation to be here and speak about the country experience on immunization, which is a very exciting topic. 

There are many reasons why children are not vaccinated and we can look at the reasons both at the health systems perspective, we can look at the community perspective, but also at the health workers perspectives. 

If you look at the health systems perspective, one of the reasons why children are not vaccinated, it’s low level of quality care. You know, no one wants to go to the health facility and not get the vaccines according to what they expect.  The other issue from the health systems perspective is the location of the offices of the health facilities. But also the waiting time in the health facility in some settings is very, very high, which makes the mothers and the caregivers not want to go to the health facility because they, they miss the hours to go to the field, the hours to go working. 

If we look to the health worker perspective, one of the challenges has to do with the limited knowledge of the health workers. No parent wants to feel insecure when they hand the children to the health worker. 

If we look at the community perspective, one crucial thing has to do with the education of the communities. If the mothers or the parents are not educated enough, they will not know the importance of being vaccinated and they will not obviously adhere to the vaccination schedule. The other things that we cannot ignore, it has to do with the beliefs of the community, the taboos in the community, and also the hesitancy to get vaccinated. So, there are many, many reasons, and those are some of the ones that I can mention at this point.  

[Angela Pereira] 

Can you also describe a scenario where populations are hard to reach compared to a scenario where vaccination hesitancy is high among the population?  

[Graça Matsinhe] 

Yes. Well, Angela, in our context in Mozambique and I believe in many, many African countries, the health facilities network is very poor, which means that in certain regions, you have people walking very long distances to reach the nearest health facility. 

Imagine someone has to walk one hour or two hours. So, in that perspective, the distance from where people live to the health facility constitutes a barrier. And one of the strategies to minimize that barrier is the outreach activities, which means that the health workers will go to the community to provide the health services, including immunization. So here we’re speaking clearly about people who live in hard-to-reach areas. The distance is one factor.  

But also you have people living in the mountains. You have people living in places with conflicts, like political conflicts, and other kinds of conflicts. You have people living in very fragile settings. While when you speak about people who are hard-to-vaccinate, here we're talking mostly about hesitancy. When we say hesitancy, we mean people who are hesitant of getting the vaccines, even though the vaccine is there and is available, most of the time because they lack knowledge about the importance of vaccination, other times they are hesitant because they don't trust the health worker who is  providing the vaccines. 

But they’re also hesitant because they are not sure about the quality of the vaccines. The most recent example, which was the COVID vaccines, I think all around the world, there was a lot of hesitancy of the vaccines at the beginning because people were not sure about the product that was being offered. But you also have places where hesitancy to vaccines is due to religious practices or religious beliefs. 

Let me give you one very precise example taking these two situations: In our daily work, we try to understand the reasons why mothers are not taking the children to get vaccines or are delaying to take the the children to get vaccines. And then we did a co-creation process where we work with the communities to try to understand the barriers of getting immunized. 

And one specific story, it was of a mother who lived something like four hours from the health facility, and then she had to wake up very early and walk and then sleep at her sister's house, which is very close to the health facility, so that in the next morning she can go to the facility. If you want to make sure that this woman will come back to the health facility, you have to be able to deliver very good quality at the health facility and make sure she doesn’t wait when she gets to the health facility. So, those are some of the issues that we encounter on a daily basis. And if you want to reduce zero-dose children, we need to make sure that we understand these complexities.  

Okay. Now, changing to the hesitancy aspect, in this certain community, we went there as the vaccination team to educate, to mobilize the population, and then vaccinate the children in that community. And for our surprise, we get there in the community and we found this father of five children, three of the children, they are above five years old, so they are no longer in vaccination age. But the most interesting thing about this parent is that he has never been to the health facility, so none of his children was vaccinated.  

The thing that was [limiting] for him, it was his religious beliefs. So, he couldn't take these children to get vaccines, he couldn’t himself go to the hospital for the healthcare because he had very strong religious beliefs that limited him to go seek health services. And with a lot of work, a lot of conversations, we were able to convince this parent to take the children to the health facility. And he was very happy after going to the health facility and get his children vaccinated. So I think this is a very good example of how hesitancy and how hard-to-reach areas are a very big challenge to reach vaccination.  

[Angela Pereira] 

Thanks, Graça, and speaking about COVID vaccine hesitancy: What lessons has the MOMENTUM Routine Immunization, Transformation, and Equity project learned from the pandemic when it comes to reaching zero-dose and under-vaccinated children?  

[Graça Matsinhe] 

COVID-19 pandemic tested our health systems, and especially the communication aspect, because there was so much uncertainty with – regarding the vaccines, the side effects of the vaccines, and the ability of protection, and so on. And the health systems had to adapt very quickly and adjust the way they communicate to the communities. So, one big lesson that we learned is the need to communicate in a way that we really address the needs of all of beneficiaries, meaning that it's not just a matter of saying, okay, get vaccinated because vaccines are good. No. We had to tailor our messages so that our communities, our population can really understand why vaccinating is important. Once people started understanding the benefits of being vaccinated against COVID, they automatically started to accept the vaccines. So, this is something that we have learned and we are transporting into our routine immunization.  

But the other thing that we learned with COVID vaccination was the need to not only involve the communities, but also make sure that they take ownership on the vaccination interventions, and they also take ownership on the decisions about their health. So, involving everyone in the community is crucial.  

The other big lessons that we took from the COVID, it has to do with forging partnerships. In the immunization program for routine immunization, we have been working with what we call the traditional EPI partners. Those are partners like UNICEF, WHO, Gavi, and other partners which are involved in immunization. But with COVID, we had to bring a new pool of partners like the private sector and many, many other players and civil society and other players. So, this was also a very good lesson because we understood that we can bring other players on board, which might not be directly involved in health issues or directly involved with immunizations, but definitely they have a role to play. 

[Angela Pereira] 

I want to go back to that community engagement piece that you discussed before. Can you share a story of when you have seen strong community engagement on vaccinations and how that has played out?  

[Graça Matsinhe]  

Yes, definitely. I was very recently in one community and we had the opportunity to meet with some community structures. Here in Mozambique, we have what we called health committees, which are people from the community with a very basic knowledge. Our intervention is to make sure that they know the basics about immunization and they can be the voices in the community on the importance of getting the children vaccinated and the benefits of all vaccines.  

Those are lay people in the community, but the way they embrace the immunization issue is very impressive, too the point that we were at a community with them and we were just questioning them: What they [are] doing, and the challenges that they have, and how they managed to identify the zero-dose children. And I was so impressed that we didn't have to say anything more than what they just explained [to] us, which showed that they really know what they have to do, and they really committed in searching for children in the community and making sure that these children are referred to the health facility to get vaccinated.  

So, for me, that was very, very impressive because those are people who are not paid. They are doing that as, you know, volunteers. But the way they understand and the way they value the vaccination process, they’re very, very engaged and very, very committed to identifying children in the community, teaching the mothers about the importance of vaccination, and referring these children to the health facilities. 

[Angela Pereira]  

And do you have a list of key ingredients that you would say are key to successful community engagement for vaccines?  

[Graça Matsinhe] 

Yes. The first one I would say is education, making sure that the people that we want to reach, they get the basic information about vaccines and the importance of getting vaccinated. 

But the other ingredient is understanding the needs of your community. You cannot just go to the community and speak about ‘you need to get vaccinated, vaccination is important,’ if you don't really understand the needs of the community.  

Another ingredient that I think is very important is to tailor our communication to that specific target group. We need to be able to speak in a language that they can understand. We need to be able to communicate in a very easy way, not just with our very complex medical terms, and also making sure that we respond to what they present us as a concern; they have so many challenges in the community, they have so many concerns, and we need to be able to deliver what they really are seeking from the health services. 

Another key ingredient, Angela, is ownership. Let’s say, if they own the vaccination process, the campaign for instance if you’re doing a campaign, or the mobile brigades when we are doing; it is much easier for the whole community to accept these interventions. So, this is very important, ownership of the community.  

And one other thing is trust. We need to make sure that our community trusts the health services, our community trusts the health workers. Otherwise, we won't be able to get into the community to address whatever issue they have.  

And finally, I think working hand in hand with community, this is, this is crucial. We need to be there in the community, we need to understand the community, and make sure that we don't leave the community behind in whatever decision we want to make. We're not making just decisions for them, but we also need to make sure that they themselves are participating in this decision-making process.  

[Angela Pereira] 

Thank you so much, Graça. And now we're going to go to Hoséa. Hoséa, tell me about the ZDROP tool in Madagascar.  

[Hoséa Rakotoarimanana] 

The ZDROP stands for the Zero Dose Reduction Operational Plan. It's a high-impact and objective-oriented technique used to identify, vaccinate, and follow up with zero-dose communities, while we also target the under-immunized children. And as a technique, it's composed of many tools to be used by the health managers. We have tools to be used by community agents. We have tools to be used by all levels of the health program. So, the ZDROP is a technique supported by many, many tools.  

[Angela Pereira] 

And how does the ZDROP tool help identify unvaccinated populations? 

[Hoséa Rakotoarimanana] 

The ZDROP is a technique that operates in the six steps, and the six steps form a cycle. First: prioritization; the second: community engagement. The third: matching of the problems and potential solutions with data. The fourth is the implementation of the plan. The fifth is the evaluation, and the last is the pause and reflect.  

The first step is the prioritization of sites from the regions of the country to the lowest level of the administrative unit, which is a sector or square, and combined with the prioritization, we do the mapping. We intervene where the needs are higher, and where we have a high number of zero-dose children or under-immunized children, and where the community is more difficult to reach. 

The second step is the community engagement to identify the problems and the potential solutions from the community itself. The third step is the matching of the problems and potential solutions with data in order to do the microplanning from the lowest level to the highest level, from a bottom-up approach. The next step is the implementation of the plan. And during the implementation of the plan, we run a stringent monitoring system and learning.  

The next step is the evaluation using three sources of data. The first source of data is the triangulated data. The second source is the lost quality assurance assembly, and the third type of data source is the programmatic data, which we use as part of the learning process. 

The last step is the most important, which is to pause and reflect. The pause and reflect is very important because if we do not take time to reflect on what we did, we cannot do better in the future. The pause and reflect is expressed at the level of the public primary of care, which is the CSP, and at the district level.  

[Angela Pereira] 

And I want to link this ZDROP tool back to community engagement, which Graça talked about quite a bit. You explained as part of the process that you're really mapping, gathering data, and then making a plan on how to actually reach those areas. How does community engagement factor into that? How do you work with communities to co-create solutions for vaccination in the areas that need it most? 

[Hoséa Rakotoarimanana]  

We are not supposed to impose solutions. It's up to the community to find out the solutions that best fit their needs. But as technical assistance, we are here to support the community to find out the solutions that fit their needs. We support, as part of our technical assistance, to match what they state as the problems with the data that is acceptable at the country and global level to transform the problems into facts, and also to transform the potential ideas from the community into solutions. 

If we take a concrete example: In one Fokontany, which is like a village, the CSP or the primary public health center with the local administration, the Fokontany and the community agents identified that the majority of households would refuse to get their children vaccinated and together identified a clear plan consisted of the interventions of the local administration to assist the community agents during the sensitization of this community while the vaccinators are doing advanced strategy. This specific activity helps us to know that the vaccinations were unknown, but due to this community engagement strategy, the vaccination status of 100% of the children in this community is now known. And after that we come to vaccinate around 19% of the zero-dose and eligible children within a month and we continue to follow up on the children until the last necessary vaccine.  

[Angela Pereira] 

Thank you so much for that example, Hosea, and I think another interesting aspect of localization here is that I understand that the ZDROP tool was actually developed in Nigeria and then adapted for use in Madagascar. So, can you talk a little bit about the adaptations that you've made to contextualize the tool for Madagascar, specifically? 

[Hoséa Rakotoarimanana] 

We began with the experiences and tools used in Nigeria and of course, made and are making continuous adaptations. And we continue to bring innovation by putting our own values in the tool.  Until now, the adaptations made are mainly on three main domains. The first adaptations we did and we are doing is on the indicators. We used the National Immunization Policy of Madagascar to set up the indicators. For example, we don't have the same priority preventable diseases. So, for Madagascar, we use what is the priority in Madagascar.  

The second adaptation is on the levels of the intervention. In Madagascar, the difference is that we come to intervene to the lowest, the lowest, the lowest level of the administration, which as I mentioned, is a square or a sector. In Nigeria, the interventions came to intervene at the district level.  

The third adaptation we did and we are doing is on the activities in the plan. Since both ZDROP in Nigeria and in Madagascar are made of community-driven solutions, naturally activities differ one from another country. So, the ZDROP is not only a high-impact practice, it's also a highly focused intervention where actions are not taken without the certitudes of minimum efficacy. And the good news is that now the districts of the capital city decided to implement the ZDROP technique with another project funded by other partners, and it's a sign of appropriation and national ownership of the technique, which Graça already mentioned is a very good thing for our support.  

[Angela Pereira] 

Thank you, Hosea, and thank you to Graça for what I think has been a really interesting conversation on the role of localization in helping us catch up and get more children vaccinated around the globe. 

And so I want to wrap up by going back to that theme of localization and asking one last question on why, from your perspective as immunization experts, why does localization matter? So, Graça, I think we'll start with you.  

[Graça Matsinhe] 

Well, Angela, localization is definitely one of the key aspects if you want to reach zero-dose children, be it looking at the health services or at the community itself. From the health system perspective, you cannot reach zero-dose children if you are not in the community, if your actions are not embedded in the community. Looking at the under-served children or the zero-dose children, they are mostly in the hard-to-reach areas, in the most remote areas. The people, the communities, which live in the last mile; therefore localization is one of the most important aspects.  

[Angela Pereira] 

Thank you. And Hoséa, I’ll ask that same question to you. Why does localization matter? 

[Hoséa Rakotoarimanana] 

Yes, localization matters. In public health, we operate using three main metrics: the people, the place, and the time. The place is the localization. Compared with what Graça mentioned, we go to the most distant, but sometimes, like for the case of Madagascar, we have unreached community which is near the health facility. 

The ZDROP is scientific, and the scientific technique absolutely identified precisely where we should go, where we should deploy our resources and efforts. Localization matters. It doesn't mean that we are not going to go there. We are going to go where we have the highest number of zero-dose children and where the community is the most, most difficult to reach. 

[Angela Pereira] 

Thank you, Hoséa and Graça, and thank you to our listeners for tuning in. We invite you to share this episode with your friends and with your colleagues and subscribe to our podcast for easy access to future episodes. 

Please stay tuned for more stories on ways that localization improves outcomes for moms and babies around the globe.  

[Outro] 

This concludes this edition of MOMENTUM Presents. For more information about our work, please visit www.USAIDMomentum.org and follow us on Twitter @usaid_momentum for additional resources.