Assessing the Use of Geospatial Data for Immunization Program Implementation and Associated Effects on Coverage and Equity in the Democratic Republic of Congo

"This research study shows that georeferenced microplans are well received, utilized, and led to changes in routine immunization service planning and delivery. In addition, the gender intervention is perceived to have led to changes in the approaches taken to overcome sociocultural gender norms and engage communities..."

In the Democratic Republic of the Congo (DRC), the integration of geospatial tools, technologies, and data into immunisation programming through a participatory process has demonstrated potential to enhance immunisation coverage and equity. The Mapping for Health (M4H) project aimed to strengthen the equity and effectiveness of vaccination interventions in the DRC, increase national geospatial capacities, and promote gender-intentional programming through the provision of geo-enabled microplans within the National Expanded Program on Immunization (NEPI). To evaluate the adoption and use of geo-enabled microplans and the complementary gender intervention in a sub-set of sites, Gavi, the Vaccine Alliance engaged health.enabled to assess immunisation service providers' acceptance and use of geospatial data for microplanning and routine immunisation service delivery and associated effects on the vaccine coverage in DRC.

Implemented in 9 provinces since 2019, MH4 aims to improve identification and immunisation of zero-dose children and overall immunistion coverage. It has been implemented by the Ministry of Health with support from the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) Consortium. To improve the effectiveness of immunisation microplans, the GRID3 Consortium supported activities to promote gender-intentional planning and to generate geospatial data and population modeling to determine the target population (denominator) and produce core geospatial data layers: settlements, health boundaries, and health facilities. These data were then used to optimise vaccination strategies in health zones in the form of geo-enabled microplans.

The cultural contexts and gendered barriers among health providers and the communities they serve can impact the adoption, access, and use of digital technologies that are intended to improve immunisation outcomes. For this reason, the M4H intervention included a gender audit, a series of gender trainings to strengthen stakeholder capacity to understand and apply gender-intentional principles in programme design and implementation, multi-sectoral stakeholder engagements, and a gender-based analysis tool. In collaboration with the Ministry of Gender and Social Affairs, these gender interventions promoted strategies to engage more women in the process of generating and utilising geospatial data and to apply gender-responsive strategies to immunisation programme planning and service delivery using the geo-enabled microplans. These activities were carried out in one study province (Kasai) in certain health zones and health areas, where the gender intervention was evaluated separately using a rapid ethnographic sub-study.

This study of M4H applied a mixed-methods design including survey tools, 19 in-depth interviews, and direct observation to document the uptake, use, and acceptance of the immunisation microplans developed with geospatial data in 2 intervention provinces and 1 control province from February to June 2023. A total of 113 health facilities in 98 health areas in 15 health zones in the 3 provinces were included in the study sample. Select providers received training on gender-intentional approaches for the collection and use of geospatial data, which was evaluated through a targeted qualitative study. A secondary analysis of immunisation coverage survey data (2020-2022) was conducted to assess the associated effects on immunisation coverage, especially changes in rates of zero dose children, defined as those aged 12-23 months who have not received a single dose of Pentavalent vaccine.

All health zones and health areas surveyed in the Kasai province (49/49 health facilities) received the georeferenced data. Almost the entire Haut-Lomami province, 98% (45/46), received the georeferenced data; no georeferenced tools were received in Kasai Central province (16/16), which is the control province. At the time of the study, different maps generated by the project were observed by the research team to be taped to the office walls of almost all (98%; 48/49) of the health facilities investigated in the Kasai province and 70% (32/46) of the walls of the Haut-Lomami province. Unanimously, respondents mentioned their satisfaction and affirmed that the maps were an important addition in general and that their use in vaccination activities made it possible to improve their knowledge and acquire more information on the respective entities.

Overall, the mapping was well accepted by various stakeholders. Positive aspects include the production of better-quality maps, enabling more accurate location of sites compared with the old handwritten maps, along with the production of more accurate population estimates and population densities, enabling better planning of vaccination activities. Negative aspects were related to the imperfection of the maps, which had some omissions or inaccuracies of specific customary landmarks.

Almost all (94%) of health facilities in the intervention provinces use geospatial data for routine immunisation programme implementation in their health areas. The interviews unanimously emphasized that georeferenced data was important in the planning process. They made it possible to improve information relating to the different vaccination strategies (e.g. fixed, outreach, mobile), the number of vaccines to order, the availability and location of refrigerators, and the size of the population to be covered in the context of vaccination activities.

Most respondents (69%) declared that the geospatial enabled tools are very easy to use. More than three-quarters are at least satisfied with the information contained in the tool and its use in activity planning. Most respondents agreed that the geospatial tool has reduced their working time and improved data quality.

Many of the respondents have worked for more than 10 years, directly or indirectly, in the microplanning of routine immunisation activities using a paper-based microplanning process. They identifed various facilitators and obstacles to the use of geospatial data for microplanning and routine immunisation.
 

• Examples of facilitators: the existence of a legend that makes it easy to read a map; attraction to technology; transition from analogue to digital; the desire to do things differently and better; involvement of users in the process; user support; buy-in; and use of the tool by the service provider.
• Examples of obstacles: the problem of connecting to the internet; lack of knowledge of the tool; lack of training; unavailability of logistical and financial resources; paper-based nature of most of the tools used in vaccination; the fact that most of the tools are intended for people who are not too literate in terms of technology; requirement of a substantial investment; and old habits.

Respondents confirmed that the community had taken part in the process through the community animation cells (CACs) with the agreement of the local authority, applying the principle that "whatever you do without me, you do against me". The head nurse of health areas organised briefing meetings to enlighten community members on the merits of mapping data. However, the community was perceived as both a barrier and an enabler:
 

• Example of a barrier: There was mistrust on the part of the population in some communities, who were not accustomed to seeing sophisticated technological devices. In some health zones, the local population believed they were being expropriated from their land, requiring repeated explanations despite prior authorisation of the village chief. In some cases, the community resisted the activities outright.
• Example of an enabler: The community contributed feedback for the validation of mapping data collected.

Highlights from the analysis of the gender intervention:

• Interviews with all gender training participants (14/14) in the targeted health zones in Kasai province revealed that this was a good training course focusing on gender considerations. Field teams are now starting to disaggregate data in terms of gender and increase women's participation as vaccinators. Knowledge of vaccination teams has improved, and gender principles were included in vaccination activities and complimented the geo-enabled microplans for better immunisation coverage.
• Most of the community members who took part in this study recognised that the gender training helped them to solve problems linked to inequality and discrimination between men and women in the community, starting with immunisation but also more generally. All the participants in the interviews recognised that now, some women are involved in vaccination activities in the community.
• Most respondents acknowledged that this focus on gender has enabled them to involve women and men in microplanning, awareness-raising, and mobilising mothers for immunisation. They also noted that complementarity between women and men is essential to reach zero-dose children and children lost to follow-up or incompletely vaccinated children in the community.
• The quantitative analyses showed that georeferenced microplans may have contributed to a dramatic and sustained trend of high immunisation coverage in the intervention site of Haut-Lomami, which saw dramatic improvement in coverage for 3 antigens and little change in Pentavalent drop-out rate over 3 years of implementation.
• However, respondents noted that service delivery is impacted by deep-rooted social and cultural norms concerning the roles and responsibilities of men and women, constituting challenges, obstacles, or barriers to immunisation that can affect both caregivers and health workers and negatively influence the provision, demand, and use of immunisation services.
• The researchers note that, in the delivery of immunisation services, it is important to include transformative and equitable gender strategies, taking into account the socio-cultural contexts in which health workers and caregivers live and work. Gender mainstreaming must be carried out at all levels of microplanning design and implementation, in the use of georeferenced data, in conducting routine immunisation, and in monitoring and evaluation. To achieve this, awareness and action is needed at national and sub-national levels to conduct gender analyses and design gender-sensitive interventions to reduce gender-related barriers to immunisation and georeferenced data use. 
   

In conclusion: "this research study revealed important lessons for the design and implementation of geospatial data programs for immunization program planning. Community engagement and a gender-intentional approach throughout the planning, data and map creation processes are valuable to increase impact and effectiveness. More attention should be paid to economies of scale and seek out opportunities for cross-sector investment in geospatial data sets....Capacity strengthening for people involved in the creation and use of geo-referenced microplans as well as a long-term plan for maintaining and updating the data should be embedded in the project from the beginning."