How did Zambia implement?

Coordinated Stakeholders toward Shared Priorities

Zambia took multiple steps to improve coordination across ministries and partners and took a multisectoral approach to the health sector for comprehensive treatment and prevention of prevailing health issues. These actions helped establish the context and enablers for a successful health system.

Developed collaborative approach to primary health care and immunization

Zambia’s Vision 2030, a long-term plan for economic growth, prioritized “equitable access to quality health care by all by 2030” and called for improved coordination across ministries, partners, and donors.¹ In 2008, the Zambian government and other African countries signed the Declaration of Ouagadougou, committing to the revitalization of primary health care.² Accordingly, the Zambian government institutionalized the integration of immunization and other primary health care services within their National Health Strategic Plan to ensure the availability of a comprehensive package of services. In addition to vaccination, services such as antenatal care, family planning, HIV counseling, and general referrals would also be offered to the public during outreach events.

This push toward a multisectoral or “horizontal” approach to health was a direct result of influence from the top ranks of MOH, according to interviewees.

This shift toward a more horizontal approach to health service delivery has increased community access to and attendance at outreach events by creating a catchall “one-stop shop” of essential services and decreasing travel time for community members. It also increased collaboration among partners at all levels of the health system.

This collaborative approach extends to the MOH’s interactions with other parts of the government. The Zambia National Development Plan mandates ministries to function in clusters rather than silos. For instance, the district health office may collaborate with the Ministry of Community Development, Mother and Child Health to coordinate outreach, with the Ministry of Agriculture to obtain resources such as fuel and motorbikes to access hard-to-reach areas, or with the Ministry of Education to integrate immunization education in curricula or use schools for outreach sites.

Engaged faith-based organizations for health service delivery and outreach

The Zambia National Development Plan emphasizes the value of collaboration with civil society organizations, and key informants explained that this has increased, particularly in the last decade. NGOs such as the Churches Health Association of Zambia (CHAZ) are invited to annual consultative meetings led by the minister of health. These meetings include international and local donors and partners who set priorities on improving health services and evaluating the previous year’s progress.

CHAZ is an example of how deeply the collaborative spirit informs immunization efforts in Zambia. It is a Christian faith coalition formed in 1970 with the goal of organizing faith-based community groups to have a greater impact on health service delivery. In 1973, CHAZ signed a memorandum of understanding with the MOH to provide broader support for mission health institutions.³

Today, CHAZ member health institutions include Catholic and Protestant health facilities representing 17 faith organizations. It includes hospitals, rural health centers, and community-based organizations throughout Zambia that provide 40 percent of national health care services and over 50 percent of rural health care services. The government supports these facilities with essential medicine shipments, grant funding, and staff. CHAZ health facilities use the government-run vaccine supply chain, although they do have their own warehouse for supplies such as antiretroviral medications and rapid diagnostic tests.

This tight interweaving of CHAZ and government operations is reflected in the organization’s active role in national health planning. It presents at ICC meetings and is part of the EPI technical working group. Additionally, CHAZ is involved at the national level in the development of immunization messaging. CHAZ-run facilities report data through the national HMIS.

Another way the government seeks to ensure broad multisectoral collaboration is by creating mechanisms for community-level systems to offer “bottom-up” input on national health policy through formalized communication channels.

In 2006, Zambia established this approach with the creation of District Development and Provincial Development Coordinating Committees. These are multi-actor platforms that identify development priorities and submit them to the national level for review and approval.

Expanded the ICC to ensure partner diversity and broadened mandate

Zambia also developed national partnerships for immunization, as recommended by GRISP.⁴ Zambia’s ICC brings together immunization partners and donors, and plays a significant role in the immunization program by providing oversight for implementation of vaccine initiatives, reviewing evidence to make informed decisions, and lobbying for funding from the government and donors. The ICC fosters collaboration between the MOH, external partners, and community-level stakeholders. It holds considerable influence on Zambian government agencies and external partners, which facilitates funding, policy decisions, and strategic planning.

A driving factor of the ICC’s success has been its ability to broaden its composition and functions. In 2013, Zambia already fulfilled most of the requirements and recommendations that Gavi had established for ICC membership. Some roles, however, were not strongly represented, for example EPI representatives, MOH officials, and immunization experts.⁵

The decision to construct a diverse and robust ICC was consistent with recommendations from a Gavi appraisal in 2016 and 2017. By 2018, when Zambia’s ICC was considered high-functioning, expansive, and diverse, its membership filled all categories sufficiently.⁶ Today, that membership includes the minister of health (as chair), as well as partners such as WHO, UNICEF, the US Centers for Disease Control and Prevention (CDC), the World Bank, CHAZ, and PATH.

With its multisectoral composition, the ICC provides a forum for coordinating immunization investments, bolsters management of key action points, and supervises the work of appointed technical working groups and task forces. Technical experts, including researchers from the Centre for Infectious Disease Research in Zambia and key members of the Zambia Immunization Technical Advisory Group (ZITAG), are also active within the ICC, lending an evidence-based rigor to its decision making. All EPI officers—including representatives for districts, cold chain, service delivery, and M&E—are ICC members.

Such a diverse and representative ICC improves collaboration among technical experts, decision makers, and community organizations. It fosters mutual trust and expectations and enables successful uptake of interventions. While it is difficult to attribute increases in vaccination coverage to ICC strengthening, we can determine that the demonstrated commitment from the Zambian government is related to improvements in the vaccine service delivery system.

For its part, Gavi had no doubts on the matter. In August 2018, it issued an appraisal crediting Zambia’s ICC as a “key driver of sustainable coverage and equity.”⁶

Beyond expanding its membership, Zambia’s ICC broadened its mandate to other areas of health care. As early as 2010—according to our interviews—the ICC was working to include maternal, newborn, and child health.

In 2017, following a suggestion from Gavi and further discussion at an annual appraisal meeting, the terms of reference for Zambia’s ICC officially expanded to include maternal, newborn, and child health. The ICC now includes leaders from different organizations that work in these areas.

This expansion allowed for a more holistic approach to vaccination, involving antenatal clinics, traditional birth attendants, nurses, and other staff members from health facilities. Activities such as child-growth monitoring and school enrollment also had direct relevance to vaccination efforts. The expanded ICC could now advance all of these activities within its own membership. These changes to the ICC have also reduced the time available to address immunization topics, leading to calls for improving the functionality of the ICC.

The benefits of an expanded ICC membership can be seen in countries with similarly high vaccination coverage. Kenya and Tanzania, both with DTP3 coverage comparable to Zambia’s (93 and 89 percent respectively, in 2018), have also expanded their ICC membership. The Kenyan ICC comprises of MOH officials, civil society organization representatives, faith-based organizations, and additional development partners.^7,8  Similarly, Tanzania’s ICC also relies on active collaboration among various key stakeholders, such as the national immunization technical advisory group, faith-based organizations, civil society organizations, development partners, and federal ministries.⁸ From this review, we found that the coordination, collaboration, and influence of the ICC is key to the direction and oversight of a country’s EPI programming.

Formalized structures for input and feedback at national and subnational levels

In addition to the ICC, the EPI technical working group provides another important layer of insight and expertise. It allows for more rigorous, evidence-based decision making because it brings the perspectives of remote communities that are far removed from the national government.

The EPI technical working group is composed of four subcommittees: (1) M&E, (2) social mobilization, (3) cold chain and logistics, and (4) service delivery. Each subcommittee is represented in the ICC.

All of these bodies contribute to the M&E process. The MOH considers M&E a key component for decision making at national and subnational levels. A subcommittee within the M&E department at the MOH brainstorms solutions for improving data quality, and filters ideas through the EPI technical working group to the ICC. This process facilitates advocacy for new project funding, innovations, and data quality improvement.

Adapted External Policies and Guidelines to the Local Context

Zambia adapted external strategies to its local history and context, including the RED strategy for immunization and community health worker strategies. It also leveraged changes in the country’s health system and corresponding adjustments in governance to accelerate coverage.

Tailored the Reaching Every District strategy to local contexts

One of the most fundamental challenges that Zambia and other lower-income countries face in establishing their vaccination programs is the sheer difficulty of reaching distant populations. Interviewees mentioned that Zambia’s population includes several hard-to-reach communities, including nomadic and migrant populations, island communities, unregistered children, children of seasonal workers, minority religious groups, and residents of urban slums.

To increase equitable access to health care services and improve vaccination coverage, Zambia adopted the RED strategy in 2007. This WHO- and UNICEF-supported approach is intended to be adapted and used by national immunization programs to improve immunization services. RED focuses on empowering districts to manage community-level immunization programming by encouraging partnerships between districts, health facilities, and communities, and promoting the use of data in decision making. While Zambia adopted RED later than most other African countries, ^10,11,12 it learned from earlier adopters and tailored its approach accordingly.

In accordance with RED guidelines, Zambia uses a bottom-up approach to develop action plans: health facilities develop microplans in collaboration with community leaders and representatives, which are then aggregated into a district action plan,¹³ then the provincial plan. The action plans identify annual priorities, set objectives, select strategies, determine indicators to monitor and evaluate activities, and estimate required resources and budget. They are developed annually and reviewed quarterly between the districts and health facilities, and between the health facilities and community representatives in order to tailor health activities to local populations. This approach can be challenging when funding is insufficient to support all activities contained in the microplans. To prevent misalignments that contribute to inconsistent implementation, the MOH has agreed to strengthen consultation in budgeting and planning and to improve communication.¹⁴

The MOH increased the number of health facilities or outreach posts to improve access for remote populations. Through community mapping and CBVs conducting head counts, districts and communities identified the strategic locations of these sites, and in some cases, developed mobile outreach sites. Challenges remain in determining accurate population counts and district jurisdiction for migrant populations and seasonal workers. Key informants frequently discussed logistical challenges due to the lack of transport to outreach sites.

The MOH also developed a Reaching Every Child manual to provide practical guidelines on community engagement for NHC and other CBVs. Community participation in the planning and implementation of activities has led to strong ownership of the RED strategy, and health workers and volunteers have fully incorporated the strategy into their routine activities. For example, health workers, CBVs, and community leaders are trained on community mapping to identify not only hard-to-reach areas but also to explore the determinants of hard-to-reach populations and the strategies to reach every child.

According to RED, good supportive supervision catalyzes the effective delivery of immunization services. Zambia ensured supervision of routine immunization was carried out at all levels, including communities and health facilities.¹⁰ A 2016 survey of Zambia’s implementation of the RED strategy found that supportive supervision was the best-implemented component.¹⁵

Another important aspect of Zambia’s RED implementation is the involvement of its ICC in strategic planning, fundraising, and technical oversight. The ICC coordinated funding for RED with partners, and oversaw the implementation of activities, such as community training and bundling of health services.¹⁶ Resources for RED implementation remain a challenge, however, as noted in Zambia’s most recent multiyear plan for immunization.¹⁷

Improved community health worker programming

The WHO Guideline on Health Policy and System Support to Optimize Community Health Workers Programmes identifies key characteristics of high-performing CBV programming.¹⁸ These include providing guidance on clear structures of selection, cascade-based training (i.e., training of trainers), supportive supervision, remuneration, and opportunities for advancement.The guideline also addresses target population size, data collection and use, community engagement, and use of supplies and community resources.

Zambia’s 2010 community health worker strategy outlines several of these approaches related to the introduction of CHAs. The 2018 strategy includes more details related to a centralized M&E system for CBV data collection and reporting—it harmonizes compensation and supervision, formalizes and standardizes universal training, and specifies the package of health services CBVs should provide.

Zambia developed the 2018 community health worker strategy in collaboration with partners and government sectors, after reviewing best practices from Liberia, Ethiopia, Uganda, and Rwanda and adapting them to Zambia. By identifying gaps and operationalizing an approach to address remaining challenges, the strategy demonstrates Zambia’s ethos of self-reflection and self-evaluation toward its CBV programming.

As the MOH continues to work on implementing the WHO-recommended practices, challenges with CBV programming in Zambia remain. However, there is a clear national intent to integrate CBVs even more fully into the primary health care system.^19,20

Involved Community Leaders in Health Programming

Traditional and religious leaders are a vital ingredient in Zambia’s vaccination program. Many of our interviewees—from the community level to the Ministry of Health—noted that vaccine delivery has always required the approval and participation of traditional leaders, who act as gatekeepers to their communities.

The involvement of traditional leaders contributes to community ownership, buy-in, and consistent vaccine service delivery at the local level.¹⁹ GRISP, RED, and related national strategies all refer to training and engagement of community leaders as an essential piece of vaccine delivery.^{4,13,20,21,22,23}

In fact, traditional leaders were involved in identifying key challenges to address, including high poverty levels in rural areas. Traditional leaders proposed that the government ensure that essential services such as electricity, transport network, schools, and hospitals are available at the community level nationwide.²¹

Traditional leaders also participate in demand generation. The MOH holds indabas, or formal community meetings, at least once per year at the provincial level with all traditional and religious leaders in the area. The MOH created indabas in 2010 to educate community leaders on vaccination and other community health matters, distribute relevant information to the community, and address prominent misconceptions. Upon completion of an indaba, the ministry and community leaders develop a plan to address health issues in their communities.

Health facility staff meet with community leaders on an ad hoc basis, which is usually every one to three months. The leaders have an opportunity to share challenges faced in their community and suggest solutions. The purpose is to discuss planning and communication for upcoming activities including child health weeks, the introduction of new vaccines, and notification of outbreaks of disease.

Faith leaders provide space for health promoters to speak on immunization activities during their religious services. Ten to 30 minutes is allocated for health messaging to promote upcoming vaccination activities. Community health workers talk about outreach activities, giving specific details on the time and location of upcoming health education and services for community members.

Generated Demand at the Community Level

Improvements in immunization systems rely on the willingness of individuals to be vaccinated. Increasing the intent to vaccinate first requires generating demand, followed by continuously distributing information to explain how one might get vaccinated. Overcoming vaccination hesitancy requires looking at several components of decision making and behavior change. As high vaccine hesitancy leads to low demand for vaccines, addressing these key components is essential for increasing demand. Additionally, demand for vaccination requires that caregivers and communities trust the safety and efficacy of vaccines, as well as the quality and reliability of services.²²

Zambia worked to address vaccine hesitancy and increase both the demand for vaccination and intent to receive vaccination.

Educate caregivers on childhood immunization

A major approach to increasing demand for vaccination is continuous health education. Community health workers, other frontline workers, traditional leaders, and the media continually provide updated, accurate, and trusted information to community members to reinforce the importance of vaccinating children. Understanding community values and how these values relate to immunization was important in developing effective campaigns and programs. Frontline worker outreach has played an essential role in connecting parents and community members to the health system in a way that promotes mutual trust, applies context-specific values, and consequently generates demand for vaccines at individual and community levels.

Zambia’s CBVs are crucial to forming effective community partnerships. Zambia gives community health workers a significant role in educating communities on vaccination. Interview participants discussed the emphasis on community engagement and community-driven strategies to combat health challenges. This focus was operationalized in the Zambia National Health Strategic Plans and the National Community Health Worker strategies to formalize and harmonize the roles and responsibilities of frontline workers.^19,20,23,24 Both GRISP and RED recommend working with community health workers to promote demand and mobilize communities for vaccination.^4,13

Although mothers tend to be the primary caregivers in Zambia, immunization messaging and education also targeted fathers. Men are typically considered the head of the household and are therefore the primary decision makers, while women are typically in charge of decisions regarding health. Men are encouraged to accompany their partners to health facilities to register their pregnancy, and later, to come to appointments when their children are immunized. To incentivize male involvement, health centers allow women accompanied by their partners to skip the queue for antenatal care services and immunization.

These targeted messages and policies have created more vaccination buy-in from men in the community, resulting in greater knowledge and acceptance of immunization at large. In focus group discussions with mothers and fathers, it was clear that immunization was a household priority and the impact of immunization on health and disease was generally well understood.

Parents and grandparents are a vital audience because the vaccination of children depends on high levels of demand and intent among caregivers. Shifting cultural and social norms is essential for increasing demand and creating normative expectations to vaccinate children. Such norms evolve through community engagement. This evolution occurred in Zambia through high levels of community engagement in promotional messaging and various forms of outreach through trusted leaders and the media.

Used media to increase knowledge and awareness of immunization

Another crucial amplifier of vaccination messaging is the media. Collaboration with the media has helped Zambian officials ensure effective dissemination of accurate vaccine information. From the national to the community level, Zambia has created a well-structured communication system to engage the public in immunization messaging.

Zambia’s Vision 2030 laid the groundwork for media partnership. The Vision describes information as a “resource” critical to socioeconomic development.¹ Additionally, the Zambian National Strategic Plans mention media engagement as a focal point for health improvements, although the plans do not offer specific strategies.^23,24 Key informants noted that partnerships with the media regarding health topics have been in place for the last 20 years, but engagement has been particularly active within the last decade.

At the national level, the health sector and media organizations collaborate to disseminate accurate and timely information. Within the MOH, the Department of Health Promotion, Environment, and Social Determinants is responsible for media engagement. A media liaison officer is at the provincial level, and a health promotion officer at the district level connects the radio stations and district health office.

Responded to vaccine hesitancy and competing priorities

Addressing vaccine hesitancy is also important to increasing demand. Health education should include addressing vaccine-related misconceptions and myths as they come up in the community, and continuously adapting outreach messaging to address the state of vaccine acceptance in the community. One common misconception is that vaccines can cause severe sickness in children, a fallacy that seems to have been effectively addressed by community health workers in Zambia.

Competing priorities may also limit some families’ intent to vaccinate their children. Defaulter tracing and continuous follow-up are essential to ensuring that all children are immunized. CBVs conduct defaulter tracing by checking the health facility’s records to identify which children are behind on their vaccinations and following up with their parents.

If parents miss a vaccination day, an NHC member will visit them to provide information on the benefits of vaccines. If the barrier to access was other responsibilities, the NHC member will escort the child to the outreach event.

Sometimes, that education can take the form of a highly tailored intervention with a single vaccine-hesitant household.

Used under-five cards to increase intent to vaccinate at the community level

One intervention used to reinforce demand is “under-five” cards, which may be used in addition to more traditional behavior change techniques such as education to reinforce intent to vaccinate. These cards list the vaccinations given to children up to age five and are intended to be required for school enrollment starting at age seven. The cards act as a nudge for parents to vaccinate their children, list reminders for upcoming appointments, and include additional messaging on child health priorities.

Used under-five cards to increase intent to vaccinate at the community level One intervention used to reinforce demand is “under-five” cards, which may be used in addition to more traditional behavior change techniques such as education to reinforce intent to vaccinate. These cards list the vaccinations given to children up to age five and are intended to be required for school enrollment starting at age seven. The cards act as a nudge for parents to vaccinate their children, list reminders for upcoming appointments, and include additional messaging on child health priorities.

Children under five who do not have all required vaccinations listed on their under-five cards receive catch-up doses through immunization outreach activities. Schools use special immunization weeks to help ensure students are properly vaccinated. During outbreaks, representatives from the MOH visit children at school and immunize them against the pathogen. Under-five cards must also be shown when registering for the national final examination in grade 12 and when applying for a national registration card.

Some key informants at the district and community levels reported that the cards are required for school enrollment in their area and are effective in reinforcing intent to vaccinate among parents. They also reported that inconsistencies across the country in how strictly immunization regulations are applied may limit the practicality and success of this approach.