Task-Shifting Immunization Activities to Community Health Workers: A Mixed-Method Cross-Sectional Study in Sahel Region, Burkina Faso

"Communication was an important dimension in the implementation of the strategy....Data indicate that the strategy has improved vaccine coverage in the Sahel region, reversing a downward trend before the implementation period."

Task-shifting is an approach that helps to ensure fair, equal, and continuous access to healthcare services, particularly in the event of a major shortage of qualified staff leading to service interruptions. Faced with the frequent disruptions to the healthcare system and provision of immunisation services caused by terrorist attacks that began in 2015, the Sahel region in Burkina Faso initiated resilience strategies, including the task-shifting of immunisation activities to community health workers (CHWs). This strategy was designed to involve more CHWs in the vaccination delivery process and ultimately to improve the performance of the healthcare system. This article describes the strategy with a focus on content, implementation process, and results achieved.

The task-shifting strategy began as a pilot in Djibo health district in 2019 and then extended to all 4 districts of the Sahel region. CHWs included both personnel recruited through the Ministry of Health and Public Hygiene processes at the national level and other community members who support the operation of health facilities. They were trained on standardised immunisation modules and provided with vaccines by functional health facilities teams. Task-shifting was first carried out with oral antigens (oral polio vaccine and rotavirus vaccine) and then expanded to include injectable vaccines in the context of the worsening terrorist attacks and the urgent need to protect the health of local populations affected by the security and humanitarian crisis.

As part of the task-shifting process, CHWs directly engaged with the various communities, conducted home visits, and carried out advocacy with local authorities; town criers were also leveraged to convey messages, where possible, during mass campaigns (at regional, district, or local levels). These communication activities aimed to address the population's doubts and prevent poor acceptance of vaccination by the community, particularly regarding the administration of injectable products by CHWs. The CHWs used educational talks and home visits to raise community awareness. Emphasis was placed on CHWs' ability to communicate the benefits of immunisation as outlined in child health promotion leaflets. Vaccination calendar posters were also distributed to CHWs.

Communication about scheduled vaccination sessions was made door-to-door by the CHWs on the eve of the activity to get parents involved. The tools used were those recommended by Burkina Faso's Expanded Programme on Immunization (EPI), and the image boxes and posters developed with the advent of COVID-19 provided additional resources for CHWs to communicate with communities. Specific key messages emphasised by the CHWs included information about the diseases against which vaccines protect and the life-saving benefits for children, as well as broader benefits of immunisation, including the time and money saved if vaccinated persons are healthy enough to take care of their hard-won assets, such as livestock.

The aim of this evaluation was to assess the functionality of immunisation service delivery by CHWs after 2 years of implementation. The intervention was evaluated through an internal programmatic review conducted as a descriptive cross-sectional study implemented from August 1 to October 28 2022, including a survey among 31 CHWs in Dori health district. Qualitative interviews by telephone reached 32 CHWs working in villages and linked to 24 health facilities.

The administration of injectable vaccines by CHWs began in December 2019, with the supervision of 40 CHWs trained initially in the town of Djibo and providing vaccinations in areas where internally displaced persons gathered. The strategy was subsequently extended to other districts. By the end of 2021, the region had 332 CHWs trained in the strategy and regularly providing vaccination in their localities. The task-shifting to CHWs enabled 6,223 children to be vaccinated, including 180 in their first contact with vaccination services. Overall, there was a downward trend in performance indicators for all antigens from 2017 to 2019 and an upward trend from 2020 onward during the strategy implementation period.

The main difficulties identified during interviews with CHWs related to issues such as the unavailability of a suitable means of transport, such as motorcycles, or related logistical challenges.

In short, the task-shifting of vaccination activities to CHWs in the Sahel region has enabled the continued provision of vaccination services to hard-to-reach populations that are experiencing insecurity - a level of risk confirmed by the assertions of the CHWs interviewed, who occasionally encountered armed men during vaccination activities. According to the researchers, the strategy "was of vital importance during the implementation of the COVID-19 immunization roll-out plan in the Sahel region that required substantial effort to overcome reluctance and generate community support, similar to previous experiences with other vaccines, such as the polio vaccine..."

Considering the results of this evaluation, the researchers recommend:

• Provide CHWs with interactive training tools such as audiovisual firmware, audio messages, and pocket memos on immunisation for self-training and distance coaching.
• Strengthen the availability of resources for surveillance of adverse events following immunisation at the community level.
• Strengthen the integration of services at the community level for the delivery of a broader package of services by CHWs.
• Increase the financial motivation of CHWs in the Sahel region and other insecure areas who implement community-based interventions, including immunisation.
• Provide health facility teams and CHWs with financial resources for refresher training and supervision.
• Provide health facilities with resources for waste management.
• Strengthen the cold chain with adequate material and energy autonomy for CHW activities in the Sahel region.  

In conclusion: "The task-shifting of immunization activities to CHWs has been implemented successfully in a region seriously affected by terrorism-related insecurity. It holds the promise of maintaining or even improving performance if institutionalized and scaled up while improving the monitoring of adverse events following immunization by the CHWs."