Critical Success Factors for High Routine Immunization Performance: A Case Study of Senegal

"Many countries have seen stalled progress in the last decade, so identifying the factors and mechanisms for accelerating progress could be critical for expanding vaccination program reach and retention."

Analysis of diphtheria, pertussis (whooping cough), and tetanus (DTP) coverage data, with DTP1 as an indicator for access and DTP3 as an indicator for continued use of immunisation services, identifies Senegal as an exemplar in the delivery of childhood vaccines. This study uses a positive deviance case study methodology to identify and understand policies, programmes, and other contributing factors that influenced high coverage rates in Senegal, especially from 2000-2019. It was nested within the Exemplars in Vaccine Delivery project, whose aim is to identify components that supported immunisation coverage improvements across three countries: Nepal, Senegal, and Zambia. (See Related Summaries, below.)

Prior to data collection, the researchers developed a conceptual model to organise factors that impact childhood vaccination coverage globally. This model was based on the work of Phillips et al. and LaFond et al., alongside a broader review of the vaccine confidence and coverage literature. Quantitative data were collected through secondary datasets and were used to estimate routine immunisation coverage from 2000 to 2019, as well as to uncover trends related to improvements and sustainability. Qualitative data were collected between December 2020 and April 2021: key informant interview (KIIs) were conducted at the national (n = 9), subnational (n = 52), and community (n = 2) levels, and focus group discussions (FGDs) were conducted with 109 participants (community health workers and mothers) within the 9 selected districts.

The following success factors emerged:

• Strong political will and prioritisation of resources for immunisation programming supported urgent allocation of funding and supplies - example: reliable service delivery and inclusive health education
• Collaboration between the Ministry of Health and Social Action (MoH) and external partners fostered innovation, capacity building, and efficiency - example: national forums to discuss programme improvements
• Formal communication channels were established for input and feedback on priorities, interpretation of data, vaccine programming, and policies - example: media engagement partnerships (see below) to increase public awareness
• Improved surveillance, monitoring, and evaluation allowed for timely and evidence-based decision making - example: coordination meetings to facilitate use of data for decision-making
• Community ownership of vaccine service delivery supported tailored programming and response to local needs - example: volunteer community health workers and community leaders (including teachers, mayors, and neighbourhood delegates) working to set up local programmes
• Community health workers (CHWs) spearheaded vaccine promotion and demand generation for vaccines - example: the cadres of CHWs - relais ("relays"), bajenu gox ("godmothers"), and home health workers (DSDOMs) - that conduct educational activities with caregivers, discuss the benefits of vaccines and dispel misinformation, collaborate closely with community members to coordinate vaccine events, and provide support to caregivers

In Senegal, community health programming began with the Bamako Initiative of Public Health which was fully adopted in 1991. The Bamako Initiative identified community participation as fundamental for the success of primary health care. Key informants spoke to the importance of national-level support for community engagement policies and programming in order to effectively coordinate with community leaders, who may act as gatekeepers to their communities. Regional development committees within the MoH rely on coordination with community actors and representatives from community-based organisations. Community actors are invited to planning sessions to support the organization of immunisation campaigns and travel door to door on vaccination days in order to mobilise mothers to bring their children for vaccination. Community engagement is tailored depending on the community; for example, one key informant mentioned the mobilisation of local youths to spread information in their communities and remind mothers about vaccine appointments on the day.

Here is an extended example that illustrates several of Senegal's success factors: At the national level, the Association of Journalists for Health (L'Association des Journalistes en Santé, Population et Développement), an independent group of media experts, developed a "strategic partnership" with the MoH to create awareness and dispel rumours at the community level. Press caravans (defined as small-scale campaigns often at the community level) involve AJSP members visiting communities to disseminate information on health topics and to learn from community members about challenges on the ground. Journalists who are part of the press caravan are trained by the MoH and mobilised to areas that have experienced success in order to gain information about effective programming or to areas that have experienced challenges in order to share lessons learned. In addition, collaboration with local radio channels was mentioned by participants in all regions assessed for this study (Dakar, Ziguinchor, and Tambacounda). Stations may provide airtime for vaccination-specific broadcasts or commercials for the MoH. Key informants mentioned that peer-to-peer learning, facilitated by the radio, supported demand generation in their communities.

Challenges and solutions related to achieving equitable access to vaccines in Senegal, as reported by key informants, are illustrated in Table 6 of the paper. For example, implementing outreach services to address lack of access in remote areas, scheduling vaccination services to align with community availability, and tailoring strategies for disseminating health information to circumvent challenges with female literacy.

Though some of the strategies described in this paper are unique to the Senegalese context, the researchers suggest that many of the highlighted success factors may have salience in other settings or apply to other health systems. For instance, the importance of collaboration and effective communication at multiple levels of government applies beyond vaccine delivery to the entire health system and supports a horizontal approach to healthcare. The data shared here also data also suggest that a deliberate and consistent focus on community engagement and ownership of health programming is essential to the success of any vaccine delivery system. In Sengal, adapting service delivery through community involvement to address the needs of end-users improved access to vaccines and made the system more resilient to challenges, including the COVID-19 pandemic; this lesson could be applicable elsewhere.

In conclusion: "The experience in Senegal suggests that the success and sustainability of the immunization program are supported by strong governance, collaboration, evidence-based decision-making, community ownership, and an overall commitment to health and prioritization of vaccine programming from all stakeholders and government officials....Findings from this research point to the need for programmers and policymakers to better understand the strengths and limitations of the underlying governance structures that these strategies rely on."

Full list of authors, with institutional affiliations: Zoe Sakas, Emory University; Kyra A. Hester, Emory University; Katie Rodriguez, Emory University; Saly Amos Diatta, Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation; Anna S. Ellis, Emory University; Daouda Malick Gueye, Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation; Dawn Mapatano, Emory University; Pr. Souleymane Mboup, Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation; Emily Awino Ogutu, Emory University; Chenmua Yang, Emory University; Robert A. Bednarczyk, Emory University; Matthew C. Freeman, Emory University; Moussa Sarr, Institut de Recherche en Santé de Surveillance Epidemiologique et de Formation; and the Vaccine Exemplars Research Consortium