Critical success factors for high routine immunization performance: A case study of Nepal

Abstract

Introduction The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies drive catalytic improvements in vaccination coverage are not well established. To address this gap, we identified critical success factors that may have led to substantial improvements in routine childhood immunization coverage in Nepal from 2000 through 2019. Methods We identified Nepal as an exemplar in the delivery of early childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health post, and community level, we investigated factors that contributed to high and sustained vaccine coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) Codification of health as a human right, along with other vaccine-specific legislation, ensured the stability of vaccination programming; 2) National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building; 3) Pro-vaccine messaging through various mediums, which was tailored to local needs, generated public awareness; 4) Female Community Health Volunteers educated community members as trusted and compassionate neighbors; and 5) Cultural values fostered collective responsibility and community ownership of vaccine coverage. Conclusion This case study of Nepal suggests that the success of its national immunization program relied on the engagement and understanding of the beneficiaries. The immunization program was supported by consistent and reliable commitment, collaboration, awareness, and collective responsibility between the government, community, and partners. These networks are strengthened through a collective dedication to vaccination programming and a universal belief in health as a human right.

Critical interventions for demand generation in Zambia, Nepal, and Senegal with regards to the 5C psychological antecedents of vaccination

“…All studied countries exhibited cultural norms that related to collective responsibility , with participants from the community and health sector alike stressing the importance of the collective health of their communities. Vaccinations were considered critical to children’s health by these populations, and in Nepal and Senegal, laws were codified to ensure all have access to vaccines; through codification, the governments legally confirmed the importance of community health and their responsibility in ensuring access [12, 13]. Although collective responsibility was the most prominent construct seen across the countries, interventions that utilized this construct may be the most difficult to replicate due to differences in culture and values.…”

“…While components of vaccine demand and intent are present in this model, we sought the use of the 5C model to further assess demand in our selected countries. The protocol of the primary analysis, along with individual case studies of exemplar countries and a synthesis case study are published separately [11][12][13]15].…”

“…Methods for country, region, and district selection are detailed elsewhere [11][12][13]15]. Countries were selected based on DTP1 and DTP3 coverage estimates, which served as proxies for the evaluation of the vaccine delivery system in these countries, with DTP1 as a proxy of access and DTP3 as a proxy of continued utilization of immunization services (Figure 2) [15,19].…”

“…The purpose of this study was to review interventions that key informant interviewers (KIIs) attributed to increased vaccine uptake in Zambia, Nepal, and Senegal, and assess how these interventions affected the community vaccination behaviors as seen on the 5C model. We observed innovative approaches to generating demand as part of our research in Zambia, Nepal, and Senegal [11][12][13]. Interventions were often implemented from existing global guidelines and further refined to country context [14].…”

Critical success factors for high routine immunization performance: A multiple case study analysis of Nepal, Senegal, and Zambia

“…Our research describes how countries with high vaccination rates took similar paths to success [15][16][17][18]. Through investigating drivers of high routine immunization coverage, our findings revealed the importance of structural factors, including governance processes and collaboration between in-country stakeholders, which more broadly align with requirements for strong national health systems.…”