Increasing Immunisation Coverage in Uganda

"During the past decade, immunisation coverage in Uganda has been as low as 30% in some districts. Poor social mobilisation and insufficient community participation are two of the reasons identified as major contributing factors for poor coverage. A Knowledge, Attitude, and Practices survey in 1998 found that health workers were deficient in their understanding of immunisation and that community participation in immunisation services was low, despite the willingness of communities to fully support programs. The existing top-down approach of the health system and the lack of capacity building in interpersonal skills for health workers were found to be critical inhibitors to a successful immunisation program."

Published by Basics II in 2003, this 4-page brief aims to describe the Community Problem Solving and Strategy Development (CPSSD) approach as applied in Uganda and its alignment with the Reaching Every District (RED) strategy developed and supported by the Global Alliance for Vaccines and Immunization (GAVI). Moreover, it reports on the results of the CPSSD approach, including improvements in immunisation coverage, declines in drop-out rates, and improvements in health worker and parent interpersonal communication.

"The [CPSSD] activities in Uganda have been designed to help health workers learn to work with communities, understand community perspectives about the services, and encourage community support and participation in the delivery of services, so that immunisation coverage is raised and sustained. Immunisation coverage and drop out rate monitoring have been introduced to help health workers track their progress and provide information to the communities they serve."

In the CPSSD approach:

• "Health workers are encouraged by district facilitators to interview parents in their community to discover what these parents know about immunisation services and what their perceptions are about the services.
• Health workers then attend a three-day consultation with fellow health workers from their Health Sub-District (HSD) to compile and analyse the information gathered.
• During this consultation, facilitators share information that suggests a new approach to working with parents and communities. Then the health workers develop a plan of action to apply this new approach in one community, to learn more about how to communicate effectively with individuals and communities.
• Two months after the initial consultation, health workers attend a two-day second consultation during which they share their experiences, progress, and lessons learned; this encourages the workers to learn from others' experiences....
• Following the second consultation, health workers return to their communities and perform outreach activities, such as making home visits, holding community meetings, calling sessions with local civic groups (Parish Development Committees) and LC III (Local Council) leaders, having regular discussions with community leaders, and forming partnerships with community mobilisers....
• At the end of each consultation, health workers develop a new action plan, then agree on a date for the next meeting for a continuous stream of information and education."

According to Basics II, the results of using the CPSSD approach are showing improvements in immunisation services.

After health workers shared the low immunisation coverage numbers with local political leaders, community meetings and home visits were conducted and families were encouraged to get their children immunised. As a result of this and similar efforts, "there has been a steady increase in coverage, as well as a distinct decline in the drop out rate. For example, in May 2003 nearly 1000 infants received their third dose of DPT. In May 2002 only half that number (512) had received DPT3. The district's drop out rate for DPT has declined from 39% last year to only 22% by September 2003."

The Basics II brief states that "while immunisation coverage in thedistrict had increased for a few months prior to the implementation of CPSSD, this increase was short lived, and probably resulted from the one-time release of funds from UNEPI headquarters to pay allowances formobilisers. The central level cannot sustain such financial support." Based on this project, Basics II suggests that "the relatively low cost ofimplementing the CPSSD strategy in a district, approximately USD $7,000, is leading not only to long-term and sustained reductions in morbidity, mortality and disability, but also to more cost-efficient health services."