Operational Framework for Demand Promotion: Integration of COVID-19 Vaccination into Routine Immunization and Primary Health Care

"Evidence-based communication strategies and tailored plans for priority groups, and social behavioural change programming will need to be designed, to generate demand for and acceptance of integrated services."

Three years after the declaration of COVID-19 pandemic, most countries had shifted away from the delivery of COVID-19 vaccines through mass campaigns designed to rapidly scale up coverage to a more targeted approach of vaccinating high-risk groups. For cost efficiency and sustainability, COVID-19 vaccines needed to be integrated into a package of primary health care (PHC) services delivered at key entry points and through platforms across the different points of the life course. Developed by the global Vaccine Confidence Task Team of the Vaccination Demand Hub, a network of technical partners working on promoting vaccine demand, this framework is a starting point to strategise demand programming for integrated COVID-19 vaccination.

There are both opportunities and challenges associated with this approach. On the positive side, integration of COVID-19 vaccination across the life course can expand and strengthen delivery of services and community engagement among populations who have previously not accessed or who miss out on health services. Participatory design approaches and methodologies, such as human-centred design, can engage communities and high-risk populations in dialogue and help programmers design services tailored to their needs. Monitoring people's concerns through social listening can facilitate an effective and evidence-based approach to integration. However, just as the COVID-19 pandemic revealed weaknesses in health systems, so too will integration. For instance, the costs of delivering vaccines to an age group outside of under-5 childhood immunisations are higher. A priority action for partners, stakeholders, and decision makers is to advocate for and secure adequate resources for demand promotion programming.

In this context, the framework uses the core components of vaccination demand to help guide thinking along a strategic pathway that is broad and flexible enough to be applied to any country situation. Designed to be used by programme planners, and policymakers seeking to structure integration and demand promotion to country specificities, the framework applies the core components of vaccination demand developed for the COVID-19 National Deployment Vaccination Plan by stakeholders and experts in the demand sub-working group of the Country Readiness and Delivery workstream of COVAX. The components are drawn from a paradigm developed by the Vaccination Demand Hub. Although focused on COVID-19 vaccination, they can be applied in designing demand programming for all routine immunisation as well as other PHC services.

Specifically, the framework's components include:

1. Coordination and Planning
2. Data and Evidence
3. Communication Strategies and Plans
4. Service Experience
5. Community Engagement and Social Mobilisation

Throughout these 5 sections are country examples, practical tips, and illustrative figures that are meant to guide and inspire the reader.

Some of the takeaways highlighted in the framework:

• Focus on demand aspects of integration: Integrating COVID-19 vaccination, whether into routine immunisation services or into wider PHC services, requires careful planning and preparation, social and behavioural data from across services, additional human and financial resources, coordination with new non-health partners, health worker training, and community mobilisation. Ensuring that health workers are motivated and believe in the value of COVID-19 vaccines within integrated services and are equipped with interpersonal communication skills to communicate with communities and clients will be key.
• Build stronger demand programmes: The COVID-19 pandemic was a disruptor of society and health systems. Routine immunisation coverage has dropped, and the number of zero-dose children has risen sharply in some places. Integration offers the opportunity to: build stronger, streamlined health services; strengthen health worker capacity; expand the reach of primary health care; and build demand for integrated services. Integration can help build new partnerships and strengthen coordination with existing partners. Investments in integration can also create sustainable cost efficiencies and improve access to a wider range of services tailored to the needs of individuals and their communities.
• Identify delivery platforms across the life-course: COVID-19 vaccines will be delivered through different platforms according to different age groups and people's health needs across the life-course. To reach new priority groups, demand programmes can be developed in collaboration with partners to leverage communication platforms, integrate messages, and build new partnerships including with non-health sectors. Older adults are a priority population and will require innovative ways to be reached and to generate demand for vaccination and other services.
• Ensure the availability of quality services: The availability of quality integrated PHC services, including trained and remunerated health workers, together with a reliable, adequate, and reliable supply of vaccines, is fundamental to acceptance and uptake by communities, households, and individuals.
• Monitor and report progress of integration: Achieving robust vaccine confidence and demand for COVID-19 vaccination requires each country to plan and track the progress of integration. The critical components for demand are a useful approach for identifying challenges and adapting programming quickly according to country needs. Applying a simple COVID-19 vaccine integration scale can help countries to measure overall progress of integration.

The resource concludes with links to further reading and a bibliography.