Why is Zambia an Exemplar?
- Zambia has maintained consistently high coverage of DTP1 since the early 2000s, while simultaneously closing the gap between DTP1 and DTP3 coverage.
- Improved immunization rates cannot be explained by an overall improvement in Zambia’s economy or increases in health spending.
For the purposes of this study, we define “exemplars” as countries that have proven to be positive outliers in increasing immunization coverage (using DTP1 and DTP3 as proxy indicators). Their success cannot be statistically attributed to economic growth, as reflected by gross national income, gross domestic product, total health spending, or levels of development assistance for health.
Zambia was selected as an exemplar due to its improvements over time. Its improvement in DTP3 coverage from 2000 to 2017 exceeded that of its peers. See the Methodology section for more information on country selection.
DTP3 Coverage & GDP per Capita in Zambia, 2000 - 2017
Province-level DTP3 coverage in Zambia
Existing literature describes the essential components of a functional and effective vaccine delivery system. For example, the Global Routine Immunization Strategies and Practices (GRISP) document describes a comprehensive framework of strategies and practices for routine immunization. 1 The Reaching Every District (RED) guide defines five strategies to equitably increase immunization coverage rates: (1) planning and management of resources, (2) reaching all eligible populations, (3) engaging with communities, (4) conducting supportive supervision, and (5) monitoring and using data for action.2
In addition, evaluations such as the Africa Routine Immunization System Essentials project and the Full Country Evaluations conducted for the Gavi, the Vaccine Alliance have documented factors contributing to coverage improvements, how vaccination programs are being implemented, and obstacles to immunization.
In this case study, we build on that body of knowledge by describing the specifics of implementation and execution in Zambia. We further explore the drivers behind Zambia’s exemplary vaccine delivery system to generate hypotheses related to health facility readiness, intent to vaccinate, and community access within the context of governance and finance, health systems, and past and present interventions.3
Our findings hypothesize that several factors contributed to a vertical alignment of priorities necessary for successful vaccine programming: strong collaboration and communication between the Zambian government, partners, and communities; and effective coordination between the national and subnational levels. Based on actions taken to improve Zambia’s immunization program, we propose the following recommendations for other countries aiming to improve vaccine coverage.
Enhance health facility readiness and community access by:
- Prioritizing community access as a common goal and providing the tools to monitor and evaluate programs.
- Investing in human resources and health systems infrastructure to ensure an adequate supply of materials and personnel to increase access, reliability, and convenience for community members.
- Systemizing a bottom-up approach to evidence-based decision making. Foster subnational responsibility in program planning, reporting, management, and evaluation, and build capacity for using data among workers at both national and subnational levels.
- Ensuring that vertical funding mechanisms that focus on specific issues also contribute to the strength of the overall immunization system.
- Coordinating stakeholders toward shared priorities. Improve coordination across ministries and between the government and external stakeholders toward common priorities. Use a multisectoral approach to encourage pooled resources from partners and donors.
- Adapting external strategies to the local context. Formalize structures for input and feedback from representatives at national and subnational levels to ensure that interventions and their implementation meet the needs of stakeholders and beneficiaries.
Build intent to vaccinate by:
- Involving community leaders or representatives in health programming. Work with communities to ensure priorities and programs are responsive to local needs. Engage with community leaders to build ownership and to promote immunization.
- Creating normative expectations at the community level to generate demand. Disseminate accurate and consistent information through multiple platforms to educate community members on immunization and increase intent to vaccinate.
Zambia Vaccination Schedule
Immunization coverage over time, with related events
World Health Organization (WHO). Global Routine Immunization Strategies and Practices (GRISP): A Companion Document to the Global Vaccine Action Plan (GVAP). Geneva: WHO; 2016. Accessed July 9, 2021. https://apps.who.int/iris/rest/bitstreams/908228/retrieve
World Health Organization (WHO). Reaching Every District (RED) A Guide to Increasing Coverage and Equity in All Communities in the African Region, 2017 Edition. Brazzaville, Republic of Congo: WHO; 2017. Accessed April 16, 2021. https://www.afro.who.int/sites/default/files/2018-02/Feb%202018_Reaching%20Every%20District%20%28RED%29%20English%20F%20web%20v3.pdf
Phillips DE, Dieleman JL, Lim SS, Shearer J. Determinants of effective vaccine coverage in low and middle-income countries: a systematic review and interpretive synthesis. BMC Health Serv Res. 2017;17(1):681. DOI: 10.1186/s12913-017-2626-0