Health Systems Strengthening

Key Evidence: In a study of equity in vaccine uptake by socioeconomic group in four Nordic countries, Denmark, the country with the largest percentage point difference between the highest and lowest socio-economic groups (14%- compared to 1-4% points in the other countries) and where vaccines are administered by general practitioners, had the lowest MMR coverage among children <2 years of age (83%). Countries, where preschool children are vaccinated in ‘well-baby’ clinics, had a higher overall MMR coverage at 91-94%, with a more equal distribution between socioeconomic groups.

Key Evidence: In a review of studies from Europe and Australia, researchers found evidence that primary care models which utilize well-baby clinics had fewer gaps in vaccination coverage associated with socioeconomic inequities compared to similar countries which did not make use of these types of clinics.

From the VoICE Editors: All countries included in the review were high-income countries; the authors note potential limitations in translation of findings to low- and middle-income countries.

Key Evidence: A systematic review of 8 African countries that had wild polio virus transmission and significant polio eradication activities found evidence that the huge investments made in polio have strengthened capacity in almost all aspects of the overall immunization systems, especially in the areas of microplanning, service delivery, capacity-building (especially supportive supervision and on-the-job training), and program management. This led to substantial increases in coverage of other routine vaccinations – BCG, DPT, measles – in all 8 countries over a 25-year period (1989-2014), including a more than a 3-fold increase in DPT3 coverage in 2 countries and a more than a 2-fold increase in 3 other countries.

Key Evidence: The expertise and assets gained through efforts to eradicate polio at least partially explain the improvement between 2013 and 2015 in vaccination coverage of DPT3 in six out of ten “focus” countries of the Polio Eradication Endgame strategic plan. This includes substantial increases in vaccination rates in India, Nigeria, and Ethiopia, which, combined, reduced the number of children not fully vaccinated with DPT by 2 million in 2 years.

Key Evidence: Communications and organizing skills and strategies developed by the India Social Mobilization Network (SMNet) — a 7,000 largely female work force created in 3 states as part of the polio eradication program to address deep-rooted sociocultural resistance to immunization in some of the most marginalized and at-risk communities- lead to strengthening of communications and social mobilization capacity of the national immunization program and contributed to sharp increases in immunization coverage of all routine childhood vaccines. These strategies, which can be applied to other health goals and priorities, included training and use of religious leaders, teachers, shopkeepers and others as community “influencers”; highly-skilled interpersonal communications; media management and evidence-based planning.

From the VoICE Editors: The authors report successes such as Uttar Pradesh, rates of full immunization coverage increased from 36% in 2009 to 81% in 2016.

Key Evidence: A survey of 23 countries in all WHO regions found that activities to eliminate measles and rubella, including vaccination campaigns, have strengthened the countries’ overall routine immunization systems in a number of ways. These include microplanning that led to revised catchment populations and denominators for target-age children, expansion of cold chain systems that extended the reach of immunization, strengthening of surveillance and of outbreak preparedness and response for vaccine-preventable and other diseases.

Key Evidence: Tens of millions of volunteers, social mobilizers, and health workers have participated in the Global Polio Eradication Initiative. The program contributes to efforts to deliver other health benefits, including health systems strengthening. Polio eradication legacy efforts include documenting and applying the lessons learned from polio eradication and transitioning the capacities, assets, and processes of polio to other key health priorities.

Key Evidence: Efforts to eliminate measles — which has been called a public health “canary in the coalmine” since it’s a sign of weak health systems — can also serve to strengthen immunization programs as well as the broader health systems. These efforts include improving infection prevention and control practices in health care facilities, disease surveillance and outbreak detection systems, and countries’ ability to prepare for and respond to infectious disease outbreaks.

Key Evidence: A study of over 80,000 children in Kenya designed to understand the role of inadequate health systems on childhood survival beyond 59 months of age showed that a higher per capita density of heath facilities resulted in a 25% reduction in the risk of death. However, user fees for sick-child visits increased the risk of death by 30%.

Increases in vaccine coverage and the introduction of new vaccines into LMICs have had a major impact in reducing mortality. Vaccination programs for ten selected pathogens will have averted an estimated 69 million deaths in 98 low- and middle-income countries between 2000 and 2030. Most of this impact has been concentrated in a reduction in mortality among children younger than 5 years (57% reduction), most notably from measles. These public health gains are predicted to increase in coming decades if progress in increasing vaccine coverage is sustained.

Key Evidence: The detection of H1N1 influenza virus in Mexico in 2009, and subsequently throughout other countries in the Americas, benefited from the laboratory experience with measles and rubella in the region, leading to the rapid detection of, and response to, what eventually became a novel pandemic virus.

Key Evidence: The Government of Nigeria used the Incident Management System (IMS) to establish a national Emergency Operations Center (EOC) as part of a new national emergency plan for the global polio eradication initiative. The use of IMS through the EOC changed the operational tempo, accountability measures, and programmatic success of the polio program. This existing infrastructure was in place and leveraged to contain the outbreak of Ebola.

Key Evidence: This paper presents the first cost-benefit comparison of improved water supply investments and cholera vaccination programs. The study results showed that improved water supply interventions combined with targeted cholera vaccination programs are much more likely to yield attractive cost-benefit ratio outcomes than a community-based vaccination program alone.

Key Evidence: A systematic review of studies examining the broader economic impact of vaccination in low-middle income countries (LMICs) found that vaccination programs may improve the financial sustainability and affordability of healthcare programs in LMICs. The use of vaccines as part of a treatment cluster, or in combination with other infrastructure projects (such as water management systems) to maximize community health outcomes, offers opportunities for cost sharing between programs.

Key Evidence: A recent review looks at evidence linking vaccinations in early infancy to childhood development services. BCG and DPT have the highest coverage of any vaccines worldwide and are typically administered within 6 weeks of birth. This timing offers the opportunity to deliver a range of early childhood development interventions such as newborn hearing screening, sickle cell screening, treatment and surveillance, maternal education around key newborn care issues such as jaundice, and tracking early signs of poor growth and nutrition.