"The level of vaccination coverage in a given community depends on both service factors and the degree to which the public understands and trusts immunization services." - Michael Favin and Asnakew Tsega
This summary along with accompanying video ("My Village My Home: Strengthening Routine Immunization in Malawi" - see below) describes a community monitoring of immunisation activity in Malawi. Since 2011, in collaboration with Malawi's Ministry of Health (MOH), United States Agency for International Development (USAID)'s flagship programmes for maternal and child health - the Maternal and Child Health Integrated Program (MCHIP) and subsequently the Maternal and Child Survival Program (MCSP) - have been working to strengthen routine immunisation in Dowa and Ntchisi (two low-coverage districts). One of the initiatives that has been used to do this is community monitoring of individual infants' vaccinations. Today, most of the villages in Dowa and Ntchisi, under the leadership of trained and empowered village heads and volunteers, actively track infants' immunisation status using the My Village My Home (MVMH) tool introduced by MCSP in that country in the last quarter of 2015.
History and rationale: MVMH is a poster-sized material used by volunteers and community officials to record the births and vaccination dates of every infant in a community. As the Related Summaries below explore, the MCHIP project supported use of the tool in India and Timor-Leste in 2012-2013. It allowed community leaders, volunteers, and health workers to monitor the vaccination status of every young child in participating communities and guided reminder and motivational visits. Assessments in both countries suggested improved vaccination timeliness and coverage. In India, pilot communities had 80% or higher coverage of identified and eligible children for all vaccines. In comparison, overall coverage in the respective districts during the same time period was much lower, at 49% to 69%. In Timor-Leste, both the number of infants identified and immunised rose substantially with use of the tool compared with the previous year. Based on these findings and considering the growing evidence of the benefits of community participation in immunisation, the MCSP project supported the use of MVMH in Dowa and Ntchisi. (Note: The community monitoring activity was but one of many MCSP activities designed to improve immunisation services and their use. For example, village heads were also engaged in micro-planning of the immunisation programme at health facility and district levels and in quarterly data review meetings at district level.)
The process: MCSP contracted a local non-governmental organisation (NGO) called Parent and Child Health Initiative Trust (PACHI) to assess the interest of traditional village heads and orient them on immunisation and their tasks related to monitoring their communities' infants' immunisations, starting with selecting a volunteer from the community to assist them. MCSP also oriented health facility staff, in particular the Health Surveillance Assistants (HSAs), who have primary responsibility for immunisation and for supervising and supporting the community monitoring activity.
Community monitoring involves the village head and volunteer beginning with a census of infants in their community. They list every infant, in order of their birth, on the MVMH tool and, using the child's health passport, record the dates of vaccinations already received. They add the names of new children shortly after they are born and become aware of and add new vaccinations on the tool, either during regular home visits or at the end of a nearby outreach session (60% of vaccinations are given by HSAs in outreach sites). They inform and motivate mothers and fathers about immunisation during regular home visits as well as in meetings and other community activities. Many also assist in outreach sessions in their communities. Although rarely needed, they also do home visits to motivate the parents of a child who has fallen behind in his/her immunisations.
Many village heads, perhaps as many as half, have proposed local bylaws stipulating penalties for families whose children fall behind in their vaccinations. Most penalties are payment of cash or items such as a chicken or goat, although one penalty is expulsion from the community (never enforced). Asked about these punishments, various mothers felt they were appropriate.
Village heads receive a small government stipend. Volunteers have received only a project t-shirt, although most request additional incentives and training.
Immunisation and Vaccines
The process has worked well in the great majority of communities. Of the selected immunisation process indicators in the two districts, four reached 100%: health facilities with at least one qualified vaccinator, health facilities with updated microplans, health facilities that received supportive supervision visits during the quarter, and districts that conducted a review meeting. The remaining indicators all came in over 90%.
Immunisation coverage appears to be nearly 100% in communities where infant tracking and monitoring using the MVMH tool is well implemented (an estimated 60% to 90% of communities). An MCSP assessment of its immunisation work in Malawi found that every child of over 40 mothers interviewed in eight communities was up-to-date on his or her vaccinations. The district health team conducted house-to-house surveys in 130 villages, and the results indicated that only 1.6% of infants had not commenced vaccination. 76.8% had completed or were up to date, and 21.6% had started but were more than one day behind the recommended date for receiving one or more vaccinations.
An assessment exercise, carried out in February 2017, found other positive results. Village heads and volunteers say they feel proud of their community coverage; they also feel responsible for ensuring children in their community are fully vaccinated. Every mother interviewed seemed to be not only highly motivated to have her children well immunised (and to use family planning) but also very knowledgeable about immunisation. One even explained (correctly) that a child who had received a measles vaccine still might come down with measles, since the vaccine is not 100% effective, but that the case would almost certainly be mild due to the vaccination. One group of mothers explained that their husbands always reminded them of an upcoming outreach session and often bought them cosmetics so they would look nice when they went.
While positive and promising, those involved in the project note that a minority of volunteers and HSAs are not as effective as they should be. The issue of incentives needs attention. And the quality of data needs much more attention so that the true impact of monitoring and other initiatives on coverage can be known.
USAID, MOH, PACHI
"My Village My Home: A Tool That Helps Communities Track Vaccinations of Individual Infants", by Michael Favin and Asnakew Tsega - sent via email from Mike Favin to The Communication Initiative on February 7 2018. Image credit: MCSP, Asnakew Tsega