Community Monitoring of Individual Children's Vaccinations: Six Country Experiences

Engaging communities to monitor every child's individual vaccinations, promote vaccination, and refer caregivers with under-vaccinated children are strategies that can improve both immunisation services and their appropriate use in low- and middle-income countries (LMICs). Informed by experiences with these strategies, this brief details initiatives in 6 countries facilitated by two United States Agency for International Development (USAID) programmes, and with technical support from John Snow, Inc.: the Maternal and Child Health Integrated Program (MCHIP) from 2009 to 2014 and the Maternal and Child Survival Program (MCSP) from 2014 to 2019. Most of these experiences used a simple community tool called My Village Is My Home (MVMH), more information about which may be found at Related Summaries, below.

As MCSP explains, unsatisfactory vaccination coverage in LMICs often reflects services that are not sufficiently accessible, convenient, reliable, or friendly. It may also reflect a lack of public understanding or trust in vaccination and/or vaccination services. In addition, various sociocultural factors affect the likelihood that families make the effort to get their children immunised.

This is where community members have a role to play - by assisting in planning services, supporting logistics (helping move vaccines and people), supporting vaccination sessions (mobilising families for outreach, organising crowds, recording information, providing practical information to caregivers), explaining vaccination and motivating fellow community members, flagging issues that need to be addressed, and monitoring and evaluating services.

MVMH was initially developed in India in 2003 by a MCSP/USAID predecessor project. Posted in a public place such as a community centre or local government office, the tool is intended to create a social expectation that families will keep their children up to date on vaccinations. In most cases, local volunteers (traditional or elected leaders and/or community-based health workers or volunteers) conduct a community census to compile the names and birth dates of all infants. They then transfer this information to the tool, starting with the oldest in the bottom row and moving upward. A roof covers the listings to show that the community is like a house whose strength depends on the quality of the supporting materials, in this case bricks or blocks, each of which represents one vaccination dose of one child. Thus, each vaccination of a child from the community strengthens the entire house and protects the entire community from vaccine-preventable diseases. Ideally, use of the tool should inform and motivate caregivers, local leaders, and volunteers, as well as professional health staff, to have more infants vaccinated, and sooner.

The brief continues with descriptions of the MCHIP/MCSP country experiences over a 10-year period with community monitoring of vaccinations, explaining how the MVMH tool was implemented in each context. Table 1 in the report provides comparative information by country on various aspects of community monitoring. Where possible, the descriptions include information on the results of the initiatives. In brief:

1. India: The project's assessment found coverage rates for all vaccines at more than 80%, with only 1.9% of children unimmunised, among children tracked in MVMH communities in Jharkhand. In comparison, coverage in non-MVMH districts in the state during the same time period was much lower, at 49% to 69% (Annual Health Survey 2011-12 data). Timeliness of vaccination (children being vaccinated at or shortly after the recommended ages) also improved. Almost all health workers and community members interviewed during the study period were satisfied with the tool and felt that it had contributed to improving the community's overall awareness of the need for and importance of immunisation.
2. Timor-Leste: To assess the impact of MVMH, data from several small communities were compared to data from the previous year (before community monitoring). The number of infants known and number immunised rose substantially with use of the MVMH tool (by around 50% and 25% respectively). Prior to the use of the MVMH tool, it appeared that only the most accessible infants were in the system, and that those harder to reach were being left out, at least partially because of the diffculty of reaching children in remote mountain communities. The timeliness of vaccination also improved in the MVMH communities; earlier, many vaccine doses were given to children who were too young to receive them (according to the national vaccination schedule) or past their due dates. Interviews with parents, local leaders, volunteers, and local health staff indicated that most respondents understood the purpose of the tool (i.e., engaging the community in monitoring the immunisation status of its children and identifying those in need of follow-up) and the processes involved (i.e., community registration of children and vaccine doses and monitoring of due doses); they also felt very positive about the MVMH tool.
3. Malawi: The project engaged a non-governmental organisation (NGO) called Parent and Child Health Initiative Trust (PACHI) to orient communities and train village heads (VHs) and volunteers to implement community mobilisation and monitoring of vaccinations in nearly 2,000 communities. The almost universal presence of home-based records facilitated updating of the MVMH tool. VHs and volunteers discuss vaccination in frequent home visits and community meetings, which has resulted in well-informed and motivated families. Timely and high vaccination coverage is almost universal in the most of these communities. Based on assessment interviews carried out in February 2017, there is great enthusiasm for the initiative among health workers, VHs, volunteers, and mothers.
4. Zimbabwe: During a rapid assessment, most of the staff in the 10 facilities in Chipinge and Makoni districts in Manicaland province where MVMH was introduced noted improved documentation of return dates on cards and in Expanded Program on Immunization (EPI) registers. Immunisation had become more of a regular agenda item at health centre meetings and in meetings between the health facility staff and village health workers (VHWs). Also, health workers met more regularly with VHs and VHWs, and VHs were more insistent that health facilities ensure an adequate supply of vaccines and cards so that coverage does not suffer.
5. Nigeria: In Sokoto and Bauchi states in northern Nigeria, MSCP supported several infant tracking approaches, including MVMH, as well as identification and referrals of newborns by highly respected traditional leaders. MVMH activities have commenced in all the settlements of 3 selected wards of Bauchi and Sokoto states, while the highly respected traditional barbers are referring newborns in all local government area (LGAs) in Bauchi and have started initially in 10 LGAs in Sokoto. Orientations at the LGA and ward levels were conducted for 83 settlement heads and 166 volunteers to support the settlement heads in recording and updating the MVMH tools.
6. Tanzania: As part of its immunisation support in 19 councils (districts) across 4 regions (Kagera, Tabora, Simiyu, and Shinyanga), MCSP and council staff oriented 1,296 community health workers (CHWs) and 648 facility staff on using MVMH in early 2018. After testing, the project printed 3,250 copies of MVMH. The tool was being used in 648 health facilities as of May 2018. In 6 councils of Kagera region, where CHWs know that their work will be discussed during supportive supervision, MVMH appears to have increased contact between facility staff and CHWs and generated mutual support addressing any issues.

Besides the potential to improve coverage and timeliness and to obtain a more complete listing of children eligible for vaccination, potential benefits of MVMH include:

• enabling people to take more control of their own health and their family and community well-being;
• enhancing health literacy, particularly related to immunisation;
• making health services much more accountable for providing reliable and convenient vaccination sessions; and
• demonstrating a viable approach that can be used to monitor and improve other public health actions in addition to immunisation, including vitamin A supplementation, growth promotion, and antenatal and postnatal visits.

Certain facilitating conditions appear to facilitate the effective use of MVMH:

• A cadre of community-based individuals, normally village leaders and some type of community health worker or volunteer, who are willing to become actively engaged in immunisation.
• Health services that are reasonably accessible, reliable, and welcoming. (Ideally community monitoring should be accompanied by enhancements in service provision.)
• Incorporation of highly respected community-based leaders or workers, such as the VHs in Malawi and Zimbabwe and the barbers and VHs in Nigeria, into health systems.

The brief notes challenges countries may face in implementing community monitoring and the MVMH tool, including selection and supervision of appropriate community collaborators and issues related to reimbursing volunteers for their time, effort, and expenses. (Local volunteers have been found to appreciate non-monetary incentives such as public thanks and recognition in meetings and on local radio.)

When such challenges are worked through, according to MCSP: "Perhaps the 'bottom line' is that such efforts modify widely-held concepts of responsibility for health, so that the health system is perceived as not only responsible for providing services, but also for actively engaging with communities, collaborating with them, and soliciting their feedback. Likewise, communities are no longer responsible simply for using services but also for improving those services and using them as intended to prevent vaccine-preventable diseases."