Leveraging the CORE Group Partners Project Polio Infrastructure to Integrate COVID-19 Vaccination and Routine Immunization in South Sudan

"Integration provided an opportunity to use the infrastructure and human resources established for polio eradication to increase availability of information and make service delivery more accessible, cost effective, and efficient."

In South Sudan, insecurity, poor infrastructure, and geographical barriers often impede access to vaccine services. Routine immunisation (RI) in children aged younger than 1 year declined due to COVID-19-related constraints and was compounded by the introduction of the COVID-19 vaccine, which was met with hesitancy and reluctance. Similar challenges were experienced in the fight to improve oral polio vaccine (OPV) uptake through the global polio eradication efforts. Thus, when South Sudan reported the first COVID-19 case in March 2020, the CORE Group Partners Project (CGPP) rapidly integrated the COVID-19 outbreak response into its ongoing polio eradication activities, leveraging the existing polio infrastructure and human resources. This article describes the integration process, results, and challenges and details the impact of the integration on coverage for both RI and COVID-19 vaccinations.

Since 2010, CGPP has built community structures in South Sudan to support polio eradication through a network of incentivised community health workers (home health promoters, or HHPs) and volunteers (community key informants). For example, community key informants are highly influential members of the community, such as teachers, religious leaders, and traditional healers, among others, who volunteer and are trained on community case definitions for priority diseases. Their established relationships with the community and the 2-way feedback mechanisms that are a core component of their work are crucial for integration efforts. CGPP also provides technical support to strengthen immunisation service delivery, build local partner capacity, and deploy risk communication and community engagement (RCCE) techniques, which include sensitisation through visits to homes and social gathering places, advocacy meetings with community influencers, and focus group discussions on COVID-19 myths. These activities are critical to immunisation demand creation and social mobilisation for outreach vaccination.

When the first cases of COVID-19 were identified in South Sudan in March 2020, CGPP began providing its focal communities with clear, actionable information to reduce spread. In April 2022, CGPP launched efforts to integrate COVID-19 vaccination and RI, as well as other key primary health care services. CGPP's integration of COVID-19 vaccination for adults with RI for children was driven by the need to generate demand and improve uptake for both the COVID-19 vaccine and OPV, particularly in hard-to-reach communities. The integrated response built not only upon CCGP's strong basis in communication (e.g., RCCE) but also used tools developed for the polio response, including real-time digital health monitoring systems, social listening mechanisms, SMS (short messaging service, or text message) reminders, and dashboards for visualisation.

Efforts to integrate COVID-19 vaccination and RI service delivery were implemented in 5 phases:

1. Assessing the need: This phase involved understanding the need and potential benefits of integration, the current landscape and gaps, and the stakeholders to engage at the national, subnational, and community levels. For example, at the community level, community dialogues, informal conversations, and volunteer observations were used to understand why communities were not accessing services and to identify bottlenecks before planning.
2. Developing multisector collaborations: CGPP South Sudan leveraged collaboration and coordination mechanisms established through polio programming, including technical working groups that brought together key players from different sectors.
3. Developing a service delivery plan: These plans had information on how to operationalise, coordinate, implement, and monitor the integration of COVID-19 vaccination and RI and focused on assuring community participation and engagement. Integrated service delivery plans were established at the county level, allowing plans to be tailored to unique contextual factors, including vaccine coverage, health systems capacity, and overall progress toward integration.
4. Assessing implementation readiness: In all 24 implementation counties, CGPP conducted readiness assessments to analyse whether minimum standards of readiness for integration of COVID-19 vaccination with RI and implementation of service delivery plans were met at partner, state, and county levels. This analysis included conversations and collaborations with implementers, partners, and other key stakeholders at each health system level.
5. Implementing and evaluating the service delivery plan: CGPP devised a hybrid approach to vaccination service delivery using routine methods and mass campaigns to allow for more opportunities for both children and adults to receive vaccinations. Both types of service delivery were accompanied by integrated RCCE messaging and social mobilisation to ensure that communities had clear, actionable information about the benefits of vaccination. Throughout the integration phases, the provision of services and the experience of community participants were evaluated and used to inform the project and adjust strategies for more effective outcomes. Overall, integration efforts prioritised coordination, training vaccinators and volunteers, development of microplans, data management, and last-mile vaccine delivery. Integrated service delivery was implemented through "one-stop shop" sessions where communities accessed RI for children, COVID-19 vaccinations for adults, and other primary health services.

As reported here, integrating health service delivery contributed to improved RI coverage among children, improved COVID-19 vaccination coverage among adults, reduced cost for service delivery, and increased access to more comprehensive health services in hard-to-reach communities. (See Figures 4 and 5 in the paper, for example.) COVID-19 vaccinations were delivered at US$4.70 per dose, a cost substantially lower than other reported delivery mechanisms.

While integration can yield positive results such as these, "it requires clear policy guidelines, commitment, and strong collaboration. Challenges included resistance from stakeholders, overstretched human resources, and diversion of funding and attention from program areas, which were overcome through deliberate high-level advocacy, partnership, and intensified community engagement." For example, uptake of the COVID-19 vaccine in South Sudan was slow in the beginning, as myths and misconceptions caused vaccine hesitancy. These factors were particularly hindering to women, who feared the vaccine would impact current pregnancies and future fertility. For CGPP, harnessing the trusted relationships built over more than a decade of polio programming was integral to improving both COVID-19 vaccine and RI uptake in project areas. With clear linkages and understanding of community feedback, CGPP was quickly able to integrate RCCE messages for COVID-19 prevention and vaccination into already-established channels of information transfer. Using trusted and trained community health workers allayed fears and addressed misconceptions.

"Future efforts should account for the human resources and capacity needs to alleviate any burnout potential. CGPP listened to volunteers, health workers, and vaccinators to try to address these concerns during service delivery and other programming." Among the other recommendations offered in the paper are the following examples:

• Base integrated service delivery at the community level on understanding the community's needs, access issues, service gaps and barriers, and other key components of service uptake.
• Codesign integrated immunisation and health programming with communities, incorporating community feedback to adjust and improve approaches that are not working.
• Conduct advocacy not only at the national and subnational levels (e.g., for policies that support the use of integrated health delivery approaches) but also at the community level. For example, when rolling out integrated outreach sessions to deliver COVID-19 and RI simultaneously, CGPP received feedback that parents were not attending sessions because they feared that children would receive COVID-19 vaccines that had not yet been approved for children in South Sudan. Strong engagement with the community and constant rumour and myth monitoring through community health workers allowed CGPP to quickly address these barriers at vaccination sites.
• Collect monitoring data, and use it in making decisions, assessing integration implementation, and making course corrections.

In conclusion: "The investments made through COVID-19 response and integration - especially those to improve human resource capacity, immunization supply chain and logistics, digital tools, surveillance, data capture, and communications - have built upon the legacy of polio eradication efforts. These advances could continue to be leveraged and built upon to improve primary health care systems and access to a variety of health services for the most vulnerable communities."