Implementation Research for Immunization: Summary Report of Global Activities Supported by Gavi, the Vaccine Alliance

"[T]here is a large appetite for and appreciation of implementation research among implementers and policymakers. The emphasis on partnership between research teams and decision makers is broadly recognized as a positive approach."

The effective implementation of immunisation programmes and services (i.e., high coverage, equity, quality, and sustainability) remains a challenge in many low- and middle-income countries. This report provides overview of 3 key United Nations Children's Fund (UNICEF) initiatives to improve implementation of policies and programmes designed to increase immunisation coverage and equity as well as broader health programmes. For each of these initiatives, the report provides an introduction and background, description of the overall process, and lessons learned. In addition, the appendix includes an overview of study findings and results to date.

Since 2015, Gavi has funded the Implementation Research and Delivery Science (IRDS) Unit, in collaboration with the Immunization Unit of UNICEF and other partners such as the World Health Organization (WHO) Alliance for Health Policy and Systems Research (AHPSR), to carry out both global and country-level implementation research initiatives. The implementation research approach generally followed several steps: (i) Stakeholders were sensitised on what implementation research is and its potential benefits; (ii) in collaboration with stakeholders, priority research questions and potential related implementation research studies were identified; (iii) a research team consisting of a partnership between national implementers and researchers was convened; and (iv) implementation research staff provided ongoing technical support and training to develop protocols, conduct studies, and support the dissemination of results and recommendations.

In brief, the initiatives include:

1. The Decision-maker Led Implementation Research (DELIR) initiative - The DELIR approach aims to enhance ownership of the research among implementers. Such collaboration is also designed to prioritise research on empirical questions of local relevance, generate feasible recommendations, and integrate evidence into policy making and health system strengthening. As part of DELIR, 14 projects from 10 countries (Chad, the Democratic Republic of the Congo, Ethiopia, India, Kenya, Nigeria, Pakistan, Somalia, Uganda and Viet Nam) received small grants. Example: As part of "Negative social media messages on vaccines: How can the resultant trust deficit between caregivers and health workers be overcome? A qualitative inquiry in Malappuram district of Kerala State in India", researcher teams sought to:
   • Understand the role of anti-vaccine social media messages in influencing the relationship and trust between caregivers and health workers;
   • Understand how the deficit in caregivers' trust in health workers influences their decisions on childhood vaccination;
   • Evaluate the current communication methods (e.g., information, education and communication (IEC) materials, websites etc.) vis-à-vis the ability to address anti-vaccine messages;
   • Suggest modifications in the current communication and social media activities to improve the trust between caregivers and health workers and thereby improve vaccination coverage; and
   • Develop a set of tools for health workers (leaflets, FAQs, social media messages) and educational materials that can help to counter anti-vaccine messages.
2. The Pakistan Implementation Research for Immunization Programme - In 2016, with the financial support of Gavi and in partnership with the Government of Pakistan, UNICEF and AHPSR launched an implementation research initiative to explore and assess health system and implementation bottlenecks facing the Pakistan Expanded Programme on Immunization (EPI). Ten projects were ultimately supported, including: "Developing three-dimensional narrative to counter polio vaccine refusal in Charsadda", whose key recommendations included:
   • Addressing polio refusals should include active correction of misleading nomenclature and control of social media use by militants against the polio programme.
   • The polio programme should make active use of social media and cellular networks.
   • It would be prudent to balance the use of force with judicious restraint.

   Based on this and other projects, Table 3 in the document outlines strategies to consider to ensure the use and application of implementation research findings in EPI policies and programmes. For example, based on implementation research carried out in the districts Sargodha and Khushab on campaign and immunisation hesitancy, it is recommended to:

   • Share implementation research findings with clear policy recommendations with officials from Gavi, WHO, and provincial-federal level EPI authorities.
   • Ensure the use of electronic media/public service messages/brochures/pamphlets for raising awareness and diminishing mistrust and hesitancy towards vaccine and immunisation.
   • Convince and bring civil society organisations (CSOs) on board for social mobilisation, as they can be of assistance due to their penetration in local areas in terms of their social capital links and relations with the local community.
3. The Capacity Building Workshop on Implementation Research - In September 2017, UNICEF undertook a learning workshop in Johannesburg, South Africa, that supported colleagues engaged with 2 UNICEF initiatives: (i) the Enhanced Child Health Days (ECHDs) projects to deliver vitamin A supplements and immunisation in 15 countries in sub-Saharan Africa; and (ii) the Birth Registration for Maternal, Newborn and Child Health (BR4MNCH) projects supporting birth registration, community health management information systems, and interoperability in Ethiopia, Mali, Senegal, and South Sudan. The workshop aimed to build the capacities of UNICEF staff, government staff, and partners to design, plan, and conduct implementation research in their respective countries.

For each initiative, the report describes in detail the process, including the dissemination and advocacy seminars/workshops associated with the research communication. Also examined are the successful factors as well as the challenges. A number of lessons were common across the research projects:

• There was a need to allow more time for each step in the process, with time built in for capacity-building activities and collaboration with local stakeholders.
• Roles and responsibilities of all actors involved in implementation research - stakeholders, non-governmental organisation (NGO) partners, and UNICEF staff - should be clearly defined from the outset of the project.
• Partnerships with private-sector entities and academic institutions were important to leverage their research experience and technical capacities for implementation research.
• Advocacy was needed for the inclusion of implementation research in regular programming, with dedicated programme budgets, as well as within standard monitoring and evaluation plans.

Moving forward, UNICEF stresses that it will be critical to develop a plan for supporting research teams beyond the research process itself. Participants indicated they would appreciate additional support to analyse data, write manuscripts, publish articles in journals, disseminate policy briefs, and identify additional funding support to test proposed recommendations/interventions. Moreover, many participants said they would need further support for the application and dissemination of key findings to broader and global audiences.

As reported here, UNICEF and AHPSR, with support from Gavi, are seeking to develop and implement a research programme focused on the generation of new strategies and knowledge that would enable more effective implementation of existing immunisation programmes within the health system. UNICEF is also in discussions with Gavi to set up an Implementation Research Hub for Immunization (IRI Hub), one purpose of which would be to promote sharing of information on implementation research studies and collaborations. Ultimately, the aim of these activities will be to accelerate the adoption and dissemination of successful approaches that address identified priority immunisation issues and to support Gavi's efforts to improve immunisation coverage and equity.