BBN Special

The Impeded Programme on Immunization

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Edwin Azuka Eriye

The Extended Programme on Immunization has made significant contributions to public health in the African Region, including elimination, eradication and control of life-threatening diseases. Hospitalization due to vaccine preventable diseases has been drastically reduced due to introduction of new effective vaccines. However, optimizing the benefits of immunization by achieving high universal coverage has met with many challenges. The Regional immunization coverage, though raised from its low 57% in 2000 to 76% in 2015 has remained below expected target. Worse still, it has stagnated around 70% for a prolonged period. Cases of inequity in access to immunization service continue to exist in the region. We therefore identified; insufficient funding and resources for immunization, vaccine stock-outs, and logistics, data issues and laboratory infrastructure as challenges of the EPI in Africa.

The African Region also missed the health-related Millennium Development Goal (MDGs) and has been off-track of the GVAP targets owing to the same challenges mentioned above. The persistence of these challenges poses a danger to the realization of the Sustainable Development Goals.

The introduction of multiple new vaccines has created some challenges for the existing logistics and cold chain requirements due to their current capacity. For instance, the high volume of the prefilled glass syringe presentation of the 7-valent pneumococcal conjugate vaccine, outstrips the central cold chain storage capacity of African countries with already weak health systems. Similarly, the safe use and disposal of used glass syringes and needles also pose a waste management challenge. There is need to put in place practical steps for addressing these issues for as many more vaccines get pushed into the system, they become more complex to handle. The systems seem unprepared for the quantum introduction of new vaccines.

Also, much of the laboratory needs for immunization programmes globally and indeed Africa is heavily dependent on the GPEI laboratories for polio eradication. Over 700 polio laboratory and surveillance network yet, only 23 are dedicated to polio only. The others service for other vaccine preventable diseases, which are common in the Region. Thus, the polio transition planning and winding down once again brings to fore the weakness of the health systems in supporting immunization activities in the Region.

Funding the commitment of national governments for immunization is perhaps one of the most important challenges facing immunization programmes in the African Region today. The cost of vaccinating a child is estimated at US$25-$45, baring other costs like training, supervision, communication among others. Several studies suggest that non-vaccine costs represent nearly half of the total cost per child. Between year 2016 and 2020, Africa will require a whooping US$17 billion for vaccines and vaccination services. Governments are expected to provide a third of this, which is US$6 billion leaving a gap of about US$5 billion. With increased competition for donor funding for developments and emergencies, government commitment and funding of immunization becomes very crucial. Currently, most of the African countries depend of Gavi funds to support vaccine and immunization.

As countries move on the income ladder to the middle-income bracket due to improved gross domestic product, and as they graduate out of the Gavi group, the availability of resources for immunization will become even more critical. There is thus, a dire need for a paradigm shift for governments to begin to take more responsibilities for immunization to ensure sustainable funding.

Closely linked to this is the weak involvement of communities in immunization programmes. The role of civil society and community-level work in advancing health, immunization inclusive, cannot be over emphasized. They have their roles in increasing demand for and uptake of available services through social and behavioral change interventions; ensuring government transparency and accountability; supporting resource mobilization; influencing national health policies; and supporting the monitoring and evaluation of effective programmes. Unfortunately, the level of involvement of communities and civil societies in immunization services remain weak. Effective engagement of communities is essential to ensuring continued progress toward universal access to immunization. Efforts should be made to explore ways in which community-level efforts, including those by Civil Society Organizations (CSOs), can drive demand for immunization and increase coverage.

Stock-out of vaccine is another major challenge to immunization in the African Region. It has been variously argued that reported stock-out do severe damage to the programmes if the communities are fully mobilized to demand immunization services. Unfortunately, countries continue to report stock-out of vaccines from their health facilities. For instance, in 2015 17 countries in the Region reported at least one episode of stock out of one or more vaccine at national level for duration of at least one week. For some countries, there was also shortage at district level. Further analysis of the data on vaccine stock-out revealed that stock-outs adversely affect vaccination session and constitute disincentive to mothers who bring their children to be immunized.

Data is of crucial importance to building robust national immunization programmes and ensuring the vision of universal health coverage is an increased understanding of national vaccine coverage. Understanding national vaccine coverage is critically important for monitoring the performance of immunization programmes, identifying areas within immunization systems that require improvements, and preparing for the introduction of new vaccines. Consequently, strengthening immunization data quality and coverage estimates, and using the data for improving immunization program performance, are critical steps toward improving coverage in Africa.

Unfortunately, ensuring a system of getting reliable immunization data continue to elude the programmes in the African Region due to many challenges. Some of the challenges include moving denominators and high population movements. Both WHO and UNICEF have continued to work on improving immunization data. WHO/UNICEF estimates of immunization coverage (WUENIC) serves as gold standard against with the administrative reported data are checked for accuracy. A correlation between the WUENIC and the administrative coverage indicates high reliability of the data from the countries. The analysis of DPT3 administrative data (JRF) for 2015 and WUENIC showed similar coverage in 27 countries. The WUENIC for some countries was higher than the administrative data, highlighting possible underreporting from national administrative system.

For a successful future of immunization programme in the Region, there is urgent need to tackle the technical, logistics, political and socio-behavioral impediments to progress in immunization in the Region. Pragmatic steps should be taken to address the challenges at the global, regional and national levels. Globally, though the WHO has facilitated consensus, commitment and cooperation among several partners, on vaccines standards, immunization policies and strategic direction in support of countries in this Region as well as other WHO Regions. This support results from the realization that coherent evidence-based policies and well-designed strategic direction are crucial for proving guidance to countries as they make their immunization choices. It remains for the national governments, communities, civil societies and immunization partners to key into the drive of universe access to immunization as a cornerstone for health and development in Africa and each contributing to the project.

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