ReviewUsing immunization delivery strategies to accelerate progress in Africa towards achieving the Millennium Development Goals
Introduction
Integration of health services has been defined as the process of bringing together common functions within and between organizations to solve common problems, developing a commitment to a shared vision and goals, and using common technologies and resources to achieve these goals [1]. This paper discusses how immunization services in Africa provide an ideal integration platform for other health interventions and surveillance related to child survival, as a means to strengthening health systems, and it identifies the advantages and potential pitfalls in doing so. Immunization is arguably the most successful health programme throughout the continent, making it the logical vehicle for add-on services. With a massive boost of funds in recent years to support immunization, Africa has the opportunity to lead the way in integrating other health services with immunization, having the most to gain by so doing.
The unacceptably high childhood mortality in parts of Africa occurs because effective, low cost interventions are not delivered to mothers and children who need them most [2]. The challenge for service providers is to work out how to deliver the best possible services to the most number of individuals with the resources available. Until recently, this had meant that a few programmes (such as immunization) attracted the lion's share of resources because they were successful. Despite the best of intentions of the Primary Health Care Declaration [3], high-impact health programmes have mostly been delivered vertically, not horizontally. This paradigm is now seriously questioned. A working group [4] on child survival recently reviewed child survival interventions feasible for delivery at high coverage levels in low income settings.
The urgency to scale-up child survival interventions that have proven cost-effective is especially important at a point when countries are implementing national plans to achieve Millennium Development Goals (MDGs), including the reduction of under-five mortality by two-thirds by 2015 as compared to 1999 levels [5]. Africa has more to loose than most in failing to scale up to meet these goals, bearing as it does the highest burden of childhood mortality in the world (Table 1). Of the 10.8 million under-five child deaths in 2000, around 4.4 million occurred in Africa. It is estimated that six communicable diseases (pneumonia, diarrhoea, malaria, measles and HIV/AIDS) accounted for close to 50% of childhood deaths in 2000 (Fig. 1). So far, prospects do not look good for achieving MDG-41 for the countries with the highest mortality rates. Bryce et al. describe the bleak prospect of low coverage for low-cost child and neonatal survival interventions – with the exception of immunization and vitamin A supplementation [6]. For example, a mere 3% of children are being protected by treated bed nets in malaria-endemic countries. The UN reports that sub-Saharan Africa is not on track to achieve any of the goals. Under-five mortality rates dropped from 185 per 1000 live births in 1990 to 166 per 1000 in 2005 – hardly a dent in the objective of two-thirds reduction by 2015 [7].
Strong health systems are the best way of delivering cost-effective child survival interventions in a most sustainable manner. The reality in many African countries is that health systems have been weak for a number of reasons including poor planning and forecasting; shortages of human, financial and material resources; paucity of data for decision making; weaknesses in institutional processes; and weaknesses in monitoring of performance and impact. The timeliness of this initiative towards integration could not be better. In the last five years, countries in Africa have received massive injections of financial resources for polio eradication and measles control as well as additional funding for a range of immunization-strengthening activities and the introduction of new and under-utilized vaccines. Much of the success of the countries in the region can be traced back to this increase in external resources [8].
Section snippets
Why integrate additional child survival interventions with immunization?
The real inception of Primary Health Care was in 1978 with the Alma-Ata Conference that was co-sponsored by WHO and UNICEF. It resulted in the Alma-Ata Declaration on Primary Health Care – a philosophy that espoused health for the people by the people. Its slogan was “Health for all by the year 2000” [3]. However, this new health philosophy also raised serious questions for the practitioner in the field. Should programmes such as immunization and malaria control be executed as vertical
Experience in integrating interventions with immunization
There is a growing realization that linking additional interventions to immunization can rapidly scale up available effective child survival interventions, while at the same time boost quality and coverage of immunization activities [13]. Some of the advantages and challenges for integration have been identified elsewhere [14] and are listed in Table 2.
The delivery of a package of high impact child survival interventions can work. In targeted districts in four West African countries, such
Strategic alternatives
Because immunization is delivered using a number of strategies, there are accordingly several potential vehicles for delivering additional child survival interventions with immunization. Ultimately, we consider that the delivery of additional child survival interventions together with routine immunization services may well be the most sustainable approach. But in many areas, a significant proportion of the target population does not have access to fixed health facilities, and other approaches
Spoilt for choice
With such a wide choice available, there is a need to prioritize child survival interventions that may be potentially suitable for integration – the system could well be overloaded if the bundle were to include too many interventions. When considering which interventions should be included in an integrated package for delivery through either the routine services, enhanced routine services or campaigns, it makes good sense if there is:
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A high burden of disease.
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Demonstrable cost-effectiveness of
Monitoring and evaluation
Monitoring and evaluation of integrated child survival interventions are critical to provide reliable information on the progress towards the achievement of programme targets and objectives. But harmonizing the activities across immunization and any additional services is likely to be problematic. While EPI has achieved a sophisticated system for tracking its own activities, monitoring an integrated programme is likely to prove more difficult. For instance, there may be separate data collection
Disadvantages
National immunization programmes are generally vertical in that they function largely as isolated systems, with disease-specific targets, some dedicated staff, a specific budget and purchasing system, technologies, training and other unique components. Such vertical programmes have often been viewed as counter-productive in terms of providing a broad-based primary health care service, and can have unintended negative consequences. There is a danger that if vertical programmes are implemented,
Conclusions
The advantages of integrated primary health care have been lauded for many years but have been implemented incompletely. In some locations, the immunization service is struggling, and adding another intervention might be the straw that breaks its back. More likely, where immunization performance is strong, immunization contacts may be excellent opportunities for additional child survival interventions such as de-worming or IMCI. They may even provide the opportunity for care of the newborn,
Acknowledgements
The WHO African Regional Office convened a workshop in May 2005 on integrating additional child survival interventions with immunization activities [36]. The authors wish to acknowledge the contribution of all participants and contributors to the meeting and the resulting document: “Strategic Framework for Integrating Additional Child Survival Interventions with Immunization in the African Region”.
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