Lessons Learned and Relearned to Improve Routine Childhood Vaccination: Six Insights from the COVID-19 Pandemic

MOMENTUM reaches riverine communities with COVID-19 vaccines by boat in Jammu and Kashmir, India. Credit: JSIPL

The USAID MOMENTUM Routine Immunization Transformation and Equity project (the project) was designed to mitigate entrenched obstacles to high equitable coverage of routine immunization (RI). After COVID-19 vaccines were introduced in response to the pandemic, the project worked in 18 countries to support national and subnational governments in their extraordinary efforts to vaccinate large and diverse groups of high-priority populations in record time. The project directly supported the administration of over 21 million doses of COVID-19 vaccines and made significant contributions to a range of technical areas.

The urgency to vaccinate, coupled with huge global investments, drove innovations and adaptations to old approaches and elevated immunization practices that had received insufficient attention. For the 50th anniversary of the World Health Organization’s Expanded Program on Immunization, with attention refocused on RI, the project is applying six insights from COVID-19 vaccination to achieve the global goal of equitable access to life-saving vaccines for every child.

1. Listen to communities when planning, providing, and promoting vaccination.

The rapid pace of vaccine development and roll-out gave rise to myths about the vaccine and its side effects. For those who sought vaccination services, geographic, logistic, and other barriers limited many people’s ability to get vaccinated. Despite obstacles, the project increased acceptance and uptake by listening to community voices when planning, promoting, and providing vaccination.

In India, it worked with local civil society organizations (CSOs) that used boats to bring COVID-19 vaccines to fisherfolk in the Brahmaputra Islands. Recognizing that older adults with limited digital literacy were unable to register for vaccination via mobile phones, local CSOs also offered on-site registration assistance. Under community leaders’ advice, the project created radio broadcasts and print materials in 12 languages to reach tribal and remote populations.

In Mozambique, caregivers cited poor treatment and communication at health facilities as major barriers to RI schedule completion. In response, the project designed interventions—including training health providers in interpersonal communication; facilitating coordination between health care providers and community counterparts; and introducing quality of care scorecards—that improved health care provider and client interactions.

2. Offer vaccination services at convenient times and accessible locations.

COVID-19 immunization required new strategies to reach people who were not previously the focus of vaccination services. To increase uptake, the project doubled its efforts to make vaccines accessible to priority populations in high-traffic locations and at expanded times. In Kenya, motorcycle drivers did not want to interrupt work to get vaccinated, so the project coordinated with local health authorities to offer COVID-19 vaccination at locations where drivers wait for customers, which enabled it to vaccinate both drivers and their riders. In the Democratic Republic of Congo (DRC), the project set up COVID-19 vaccination sites at markets so passersby could get vaccinated without going out of their way, and later established similar sites to provide childhood immunization at markets. The project is working in urban health centers in Lagos, Nigeria to institutionalize weekend immunization services to accommodate caregivers who cannot bring children to facilities during weekday morning sessions.

3. Use behavioral data to tailor strategies to increase uptake.

There are many reasons that people might reject new vaccines or discontinue vaccination of their children. Reasons may vary within a country by location, religion, ethnicity, and other factors. We must understand reasons so we can tailor strategies to remove barriers and facilitate vaccination. In Serbia, research found that the general public and health workers lacked a consistent and reliable source of COVID-19 vaccination information. In response, the project helped to establish a scientific advisory group, convening critical immunization institutions and experts as a single trusted source of information. The advisory group conveyed accurate COVID-19 information to health professionals and the public through press conferences and other media appearances, which mitigated rumors and corrected misinformation.

The project also took a behavior-driven approach to increase RI uptake in India, where behavioral data pointed to the importance of family support and religious norms as determinants of vaccination coverage. The project supported educational meetings separately for mothers and fathers, and oriented faith-based organizations, women’s groups, and other community leaders to immunization topics. By creating broad awareness and influencing community norms, mothers are better supported to vaccinate children.

4. Engage new partners to help achieve equitable immunization coverage.

Many people and organizations wanted to help end the pandemic. Partners not previously involved in immunization, including local organizations with the capability to reach groups that had not previously been prioritized for vaccination, joined the effort. With project support, the Ageing Concern Foundation in Kenya went door-to-door and conducted outreach at public gatherings and events in churches and mosques to educate people about COVID-19, ultimately delivering 79,397 doses of COVID-19 vaccines to older adults in six months. In India, the project partnered with the Transport Corporation of India Foundation to reach transport and workers in affiliated industries to allay vaccine concerns and increase uptake across 18 states.

This approach of engaging new partners was applied both for COVID-19 and RI in the DRC. The project facilitated 76 partnerships linking sub-national health authorities with local CSOs and other partners that supported education and awareness activities. With project-supported coaching, local health authorities have leveraged these relationships to support RI, with partners providing meeting space and vaccine transport, even in locations where the project no longer operates.

5. Invest in robust data systems that are contextually appropriate and help managers target resources.

Global partners made large investments in data systems during the pandemic. Some countries have used these investments to adopt next-generation technology, while others faced challenges with adoption. The project worked to ensure that these new systems not only supported global monitoring, but also provided data for local management.

In Vietnam, the project developed a Google form to help aggregate vaccination data so province and district officials could use it to monitor progress. In DRC, efforts to introduce a data system with individual patient records faced challenges including connectivity and over-burdened providers. The project supported a return to summary data reporting, which provided more reliable data for management decisions. The Government of India introduced a data system that integrated individual vaccination status, vaccine availability, and service scheduling. Project-designed state-level dashboards helped state and district officials use those data to identify areas with lower performance for increased attention and support. Based on this experience, the project is developing similar dashboards to identify sub-districts in 15 municipalities that need additional attention to improve RI performance.

6. Adapt strategies continuously based on what does and does not work.

The challenges posed by the rapid COVID-19 vaccine roll-out necessitated continuous adaptation. Working under pressure, the project reviewed results in real time and quickly made adjustments if a strategy was ineffective. In Ethiopia, for example, the Ministry of Health and Addis Ababa City Administration Health Bureau integrated COVID-19 vaccination into its measles campaign to reach caregivers bringing children for vaccination. However, campaign data showed lower than expected COVID-19 vaccination uptake. Working with health providers, the project modified the patient flow at vaccination sites so COVID-19 vaccines were offered before all services for the child were completed. This small adjustment contributed to a significant increase in the number of people who received COVID-19 vaccines during the campaign.

To support the Big Catch-up for RI in Mozambique, the project advised the government to conduct a pilot to allow for adaptations before nationwide implementation. During the pilot, the project learned that many health facility registries and documents needed for microplanning were missing or damaged, so it switched to community mapping to improve accuracy. The pilot phase also revealed the need for training to define and identify eligible zero-dose and under-immunized children, essential data for planning adequate vaccine stock. These lessons are being incorporated into the national roll-out of Big Catch up campaigns.

Challenges to improving equity and fully protecting every child against vaccine-preventable diseases are significant. But by mobilizing new partners, listening and responding to community needs, using data to guide work, and making adjustments as necessary, we are optimistic that the immunization community will advance local and global immunization goals.