Evaluation of the Drivers of Urban Immunisation in Uganda: A Case Study of Kampala City [Final Report]

"Inclusive planning and organization with representatives from the hard to reach areas and communities is vital to successful implementation of immunisation activities and overcoming the challenges arising from the complexity of urban areas..."

Urban settings pose unique barriers to the delivery and utilisation of immunisation services, such as multiple cultures that require service adaptations. To understand these barriers in Uganda, Gavi, the Vaccine Alliance asked the Infectious Diseases Research Collaboration (IDRC), Uganda, to conduct an evaluation of the drivers of urban immunisation in Kampala City. The evaluation was conducted in two phases. Phase one (June 2019 - May 2020) focused on demand-side drivers of immunisation coverage in Kampala (see Related Summaries, below, for the report), and phase two (June 2020 - July 2021) focused on supply-side drivers and the effect of COVID-19 pandemic and its control measures on immunisation service delivery in Kampala.

In phase two, the evaluation used a sequential transformative study design. The evaluators conducted key informant interviews with health service providers, and a health facility assessment (HFA) in 87 health facilities that included 27 observations of immunisation sessions and 238 exit interviews.

Access to immunisation was found to be high, with 96% of infants receiving their first dose of a diphtheria-tetanus-pertussis-containing vaccine (DTP1). However, only 41% of the children were fully immunised, of whom 26.6% were immunised on time. In addition to vaccine stockouts at health facilities and costs to caregivers, barriers to vaccination included:

• Limited social mobilisation and understanding of the importance of full immunisation: Inadequate information on immunisation is a barrier to full immunisation of children in Kampala and is due to: (i) Insufficient information given by health workers during immunisation sessions; (ii) low motivation of village health teams (VHTs) to conduct social mobilisation; (iii) reliance on the VHT structure for social mobilisation, which leaves out closed communities; and (iv) gaps in community involvement in immunisation by private for profit (PFP) health facilities. These reasons reflect inadequate public engagement for immunisation. As a result, there is fear and mistrust of the vaccines. This is exacerbated by negative social influences by significant others like spouses and religious leaders who preach against immunisation, as well as misinformation and conflicting messages from the media.
• Discrimination of minority groups: Refugees reported marginalisation by the providers of immunisation services, felt through: being skipped in queues, being left out during mass immunisation campaigns, and health workers being rude to their community. They also felt left out of communication on immunisation, as the mainstream media mostly used local languages when announcing immunisation services. Many refugee communities felt that the immunisation services offered were not acceptable to them - due to cultural and language challenges - which limited their healthcare seeking behaviour.
• Inadequate client-centred immunisation services (i.e., unfavourable frequency and duration of static immunisation services, low numbers of immunisation outreaches conducted, and delays at health facilities).

The evaluators find that the underlying barriers to full immunisation coverage in Kampala may be due to lack of an immunisation strategy that addresses the unique context of urban settings. These barriers include: (i) absence of a clear strategy for mobilisation and education tailored to the urban context; (ii) limited consideration of the transient urban population in planning for immunisation services; (iii) limited consideration of the socio-economic dynamics of the urban population, and presence of closed communities; and (iv) costs to caregivers.

The Expanded Programme on Immunization (EPI) in Kampala is taking steps to adapt to the challenges of immunisation in an urban setting. Activities include: revision of the vaccine requisition vouchers to improve vaccine forecasting (i.e., to prevent stockouts); allocation of vehicles to support immunisation activities; engagement of the private sector in immunisation services delivery to minimise delays at public health facilities; proposed review of the staffing norms at public health facilities in Kampala so as to address inadequate staffing; leveraging existing partner support to conduct outreach; and development of an urban immunisation communication plan to guide social mobilisation for immunisation in urban settings.

The latter plan includes the following proposed interventions: effective use of social media platforms; capacity building of community health workers to improve their knowledge, skills, and competence in immunisation; engagement of informal groups to increase demand for immunisation services; mobilisation of leaders of religious sects, cults, and resistant communities opposed to immunisation; and media advocacy to promote accurate and analytical coverage and reporting of immunisation activities.

The evaluation found that movement restrictions during the COVID-19 pandemic lockdown led to a reduction in the number of children receiving routine vaccination due to challenges in accessing health facilities by both health workers and caregivers. COVID-19 vaccination has affected routine immunisation in two major ways: (i) It has increased the workload of the already-stretched human resources for routine immunisation; and (ii) The EPI is focusing more on COVID-19 vaccination than on routine immunisation. The report notes that good coordination among partners can facilitate improvement in service delivery and utilisation of health services during a pandemic. During the COVID-19 pandemic, the mobilisation and coordination of partners helped to mitigate impact on service delivery.

The Uganda National Expanded Program on Immunization (UNEPI) uses the same approach to deliver immunisation services nationwide, irrespective of urban-rural differences. However, this evaluation has illustrated that this model of service delivery is sub-optimal in Kampala, as reflected by high dropout rates, low full immunisation coverage rates, poor timeliness of immunisation, and occurrence of measles outbreaks in the period of 2015-2018. To that end, the report offers recommendations, including at the policy level (e.g., develop a national urban health policy that is anchored in a primary health care (PHC) approach, as PHC is the platform for immunisation and other services that promote healthcare equity) and at the operational level (e.g., develop a system for tracking children's vaccination status countrywide through an electronic register).

Finally, areas for future research and evaluation are proposed. For example, given the increasing complexity of COVID-19 and its vaccination (including vaccine hesitancy, negative messaging, and limited vaccine availability), there is need to embed a prospective evaluation of the EPI's response so as to generate real-time evidence to guide decision making and provide learning for future public health crises. It is also important to strongly embed capacity building for research on vaccines and immunisation in Uganda so that local evidence informs decision making and implementation in the country.