Zambia: A leading light in Africa's immunizations

Vaccinations, according to the World Health Organization, are one of the most successful global health and development interventions of the past century, and the foundation of the primary health care system. Immunizations are also incredibly good value, with the average country-level return on investment on immunization having been estimated to be 51 times the cost. However, while the essential components of a successful vaccine delivery system are widely known, it's often less well understood how and why certain implementation strategies have been effective.

The Exemplars in Global Health program has identified Zambia as one of several countries that have made notable progress in achieving high vaccination coverage through their national immunization programs. Notably, the country increased its DTP3 coverage to 91 percent between 2000 and 2017.

In new research published by Exemplars in Global Health, it was found that the country did so by prioritizing community access and investing in its health systems infrastructure and workforce. Researchers also found that vertical funding mechanisms – development financing mechanisms for a single area from multiple sources – played a big part in strengthening the country's immunization system, along with good coordination among ministries and other partners.

We spoke with one of the researchers, Dr William Kilembe, a project director at Zambia Emory HIV Research Project in Lusaka, about how Zambia became an immunization success story.

Exemplar News: Could you summarize your findings? How did Zambia so successfully increase its vaccination coverage?

Dr. Kilembe: Zambia's immunization program has really improved over the last 20 years because we've had governments with a supportive attitude towards health in particular. The Ministry of Health tried to look at best practices from around the world and guidance from bodies such as the WHO and, in this case Gavi, related to immunization programs and tried to implement those to the best of their capability as a country. As an example, Zambia implemented some of the guidance from Gavi by creating an Inter-agency Coordinating Committee (ICC). What we've seen from the Exemplars research is that Zambia went over and above in terms of implementing some of the things Gavi suggested. For instance, the ICC played a significant role in the immunization program by providing oversight and influence over policy decisions and strategic directions, implementing vaccine initiatives, and lobbying for and procuring funding. The coordinating committee has been at the center of bringing together stakeholders to coordinate the vaccine effort. The other aspect is that Zambia has been able to use some of the best strategies developed elsewhere. For instance, the decentralization of health care delivery and health strengthening systems, and ensuring that the end-users – the community – are involved or are engaged in the decision-making. They got information from the grassroots, from the lower levels of health, right up to the district. This bottom-up approach has really been a contributing factor because you get to include and involve the community in a meaningful way, including being aware and cognizant of the cultural nuances to ensure the program is successful. We've also had quite supportive NGO and non-governmental partners and stakeholders that have funded the program to a level that made it quite successful. For instance, there was mention of the reliance on NGOs and grants to help cover the gap in outreach funding when the MoH budget falls short. Some of the things that we've tried to implement in terms of outreach in different districts have been thanks to the funding of some of these agencies, including Gavi. You also can't do vaccination without a good cold chain system, which has over the years been improved in such a way that it's sustainable and has some sustained funding. Following a two-phased effective vaccine management assessment at Ministry of Health in 2002 and 2012, Zambia took steps to ensure sustainability of the Gavi’s investment in cold chain maintenance. These steps were inclusion of a budget line for cold chain to ensure infrastructure was maintained, implementation of the cold chain EPI subcommittee represented on the ICC to oversee operations at subnational levels and deploying cold chain officers at provincial and district levels. These are some of the things that have led to a successful vaccination program.

Exemplar News: What are some of the key insights from this research?

Dr. Kilembe: I think what's important is having a good, coordinated system within a country. Coordination that's happening right from the top and takes into consideration community perspectives and other stakeholder perspectives. Making sure that the operational aspects of the program are there, including the staffing that provides the service and creates demand for the service. These are things that I see as being very important in the success of the vaccination program in Zambia, because once those things are addressed you create demand and you also create supply. You cannot do one or the other and expect things to work.

Exemplar News: The research emphasizes that Zambia took an equity lens towards improving vaccine coverage. Could you tell us more about that?

Dr. Kilembe: There was a program called Reaching Every District (RED) strategy that was introduced in 2007. It was a tailor-made program that used examples from other countries and in fact, in Zambia, it was actually developed a little later than many other African countries. Based on evaluations of RED implementation in other African countries, Zambia adapted lessons learned of the RED strategy which helped the program to succeed in local context and identify steps for capacity strengthening. It involved supportive supervision at all levels in trying to make sure that each and every health facility and each and every child that required immunization was reached through this strategy. First of all, we knew that because of transport logistics that [vaccine delivery] would be difficult in certain rural areas. In fact, those areas still have somewhat lower coverage in terms of vaccine access. We wanted to make sure this program was designed in such a way that we could reach those areas. Also addressing issues of long distances to health care facilities by community members in different populations. We identified, or rather the system identified, low-vaccine coverage areas. What had happened was that there was quite a lot of community training, using of community-based volunteers, a lot of community stakeholders – leadership at the community level to foster strong community ownership of this program. Data was also delivered to the district provincial health offices from the community-based volunteers, which means it actually went right to the grassroots to where the service would be provided.

Exemplar News: The research also mentions that vertical funding mechanisms contributed to the strength of the overall system. How did that work? And how do you draw a balance between effectiveness of vertical versus horizontal funding mechanisms?

Dr. Kilembe: We have had quite a lean health care or health system budget. As I mentioned earlier, we have quite a lot of external donors and funders that facilitate the funding. In fact, about 40 percent of the immunization program is actually funded through other partners, including Gavi. So, funding is meant for very specific programs, which could be vertical, but we would like to make sure that as we fund those programs we would also like to include messages from routine immunization. Leveraging funding that comes in a vertical way and including messages about routine immunization is one example of how Zambia actually achieved some of the success, rather than just focusing on delivering one message.

Exemplar News: There seems to have been some good coordination among stakeholders among ministries and partners. What lessons do you have regarding coordination and how has this been sustained over time?

Dr. Kilembe: The biggest lesson is that if a country has limited budgets, there is need to make sure that available resources are leveraged. A good example from the Zambia government is how the different ministries actually work together. In certain areas you would find that the Ministry of Health really works well together with the Ministry of Community Development, for instance, because there are things in common that they're dealing with. One is really primarily focused on health. The other one is focused on maternal and child health as well as community development. But they can share certain resources in terms of speaking to one another, and also have meetings that include the Ministry of Education and Ministry of Finance. These ministries can come together to discuss common areas of interest and leverage the resources that they have to achieve the common good. In this case, an example I would give you is that maybe you have a vehicle that is going to a rural part Zambia for some education-related program, but then in that vehicle you could actually have a person who's carrying vaccines in a cold storage to go and deliver vaccines to a health facility. That is one example of this sort of coordination between government ministries and trying to make sure that they can partner as well as promote stewardship in terms of their programs and whatever it is that they're doing.

Exemplar News: What lessons emerged from the research about tailoring to local context and how were they addressed?

Dr. Kilembe: You need to put things in the cultural context. In Zambia, we have hierarchy at the community level. Normally you have a chief of a certain area and you have the other subjects that fall under that, and realizing that hierarchy is really important to try and get to the grassroots, because by engaging those stakeholders, those gatekeepers to those communities, you are likely to be successful with your program, because you get a buy-in right from the start. Community engagement was critical to ensuring the program was successful. The influence of media was also very important for the purposes of promoting health care delivery and vaccine immunization program implementation. In terms of challenges, I think certain cultural beliefs may be very deep-rooted and the challenge has been to try and demystify or debunk some myths about immunization, which has been quite a challenge in some parts of the country. I remember interviewing a person from USAID who had mentioned certain areas where they actually believe like in many other parts of the world that certain vaccinations cause impotence or autism. To go beyond that has been quite a challenge. What that really helped the immunization program was that these beliefs are not general, they are actually in just selected places. Understanding the context specific challenges and tailoring solutions accordingly is important to address inequities.