From reaching every district to reaching every community: analysis and response to the challenge of equity in immunization in Cambodia

Abstract

Background An international review of the Cambodian Expanded Programme on Immunization (EPI) in 2010 and other data show that despite immunization coverage increases and vaccine preventable diseases incidence reductions, inequities in access to immunization services exist. Utilizing immunization and health systems literature, analysis of global health databases and the EPI review findings, this paper examines the characteristics of immunization access and outcome inequities, and describes proposed longer-term strategic and operational responses to these problems.Findings The national programme has evolved from earlier central and provincial level planning to strengthening routine immunization coverage through the District level ‘Reaching Every District Strategy’. However, despite remarkable improvements, the review found over 20% of children surveyed were not fully immunized, primarily from communities where inequities of both access and impact persist. These inequities relate mainly to socio-economic exposures including wealth and education level, population mobility and ethnicity. To address these problems, a shift in strategic and operational response is proposed that will include (a) a re-focus of planning on facility level to detect disadvantaged communities, (b) establishment of monitoring systems to provide detailed information on community access and utilization, (c) development of communication strategies and health networks that enable providers to adjust service delivery according to the needs of vulnerable populations, and (d) securing financial, management and political commitment for ‘reaching every community’.Conclusions For Cambodia to achieve its immunization equity objectives and disease reduction goals, a shift of emphasis to health centre and community is needed. This approach will maximize the benefits of new vaccine introduction in the coming ‘Decade of Vaccines’, plus potentially extend the reach of other life-saving maternal and child health interventions to the socially disadvantaged, both in Cambodia and in other countries with a similar level of development.

Increased immunization coverage addresses the equity gap in Nepal

“…In line with our results, a study from Cambodia showed that socioeconomic factors were most strongly associated with decreased access to immunization services, compared to other factors such as gender or rural/urban location 23 . Furthermore, social distance, that is the distance a person is from health care in terms of acceptability and affordability, was discussed as the main determinant of immunization access as compared to geographical distance 23 . Our study confirms that geographical location, or the urban/rural divide, does not contribute to differences in immunization coverage.…”

Introducing new vaccines in low- and middle-income countries: challenges and approaches

“…Use of immunization campaigns and 'outreach' strategies that target under-covered population groups is one such approach. This includes the Reaching Every District (RED) micro-planning process strategy developed in 2002 by the WHO, UNICEF and other partners, and successfully used in Africa, India, and other Asian countries [46][47][48][49]. Supplementary Immunization Activities (SIAs), also referred to as mass-immunization campaigns, employed to improve protection at population levels via increased coverage, or to achieve global elimination goals or contain outbreaks, have also shown value in reducing inequity within populations [1,[50][51][52].…”

“…RED districts receiving training and support from an immunization consultant did not reach better coverage than comparison districts without this support but obtained improvements in the quality of the program. Cambodia [46] Analysis of the social determinants of non-access to immunization and shift of "Reach Every District" to "Reach Every Community" Cholera vaccination, Zanzibar [52] Evaluation of social and cultural factors and of barriers to understand reasons for a coverage of 50% despite 94% of the adult population willing to receive free oral cholera vaccines. Campaigns should be announced at least a few months before vaccination posts open, with repeated reminders in the target communities, consider an extension of daily open hours or numbers of days for the vaccination especially in rural areas.…”

Can investments in health systems strategies lead to changes in immunization coverage?

“…Most studies in low-income countries highlight the role of maternal education and knowledge on the use of immunization services [24][25][26][27][28][29][30][31][32][33][34][35]. In these studies, lower coverage was associated with lower education and knowledge levels of mothers.…”

“…Bishai et al [24] found a positive association between socioeconomic status and immunization coverage in Bangladesh. Similarly, in Cambodia, socioeconomic status and ethnicity affected coverage rates [31]. Cutts et al [27] found that mother's employment was positively associated with completion of vaccination services in Guinea.…”