Critical Success Factors for High Routine Immunization Performance: A Case Study of Nepal

"This case study of Nepal suggests that the success of its national immunization program relied on the engagement and understanding of the beneficiaries."

Nepal has outperformed its peers by increasing its diphtheria, tetanus, pertussis vaccine (DTP3) coverage from 74% and 93% between 2000 and 2019. The purpose of this study was to identify the success factors that contributed to notable growth in childhood routine immunisation coverage in Nepal during that 19-year period. This study was nested within the Exemplars in Vaccine Delivery project, whose aim is to identify components that supported immunisation coverage improvements across three countries: Nepal, Senegal, and Zambia.

Through key informant interviews and focus group discussions (FGDs) at the national, regional, district, health post, and community levels, the researchers investigated factors that contributed to high and sustained vaccine coverage in provinces of Madhesh, Bagmati, and Gandaki Pradesh, with rolling 3-year averages of 76%, 90%, and 95% DTP3 coverage in 2016, respectively. They conducted a thematic analysis through application of implementation science frameworks to determine critical success factors and triangulated these findings with quantitative analyses using publicly available data.

The following success factors emerged:

• Codification of health as a human right - along with other vaccine-specific legislation - supported the prioritisation of vaccines in policy development, motivated health workers and female community health volunteers (FCHVs), and generated community demand. Additional improvements to the health system supported the National Immunization Programme (NIP) in providing vaccines to every child, and it provided the framework for the messaging of a child's right to be immunised.
• National and multi-national partnerships supported information sharing, division of labour, and capacity-building. Key informants from all levels reported high levels of trust, mutual respect, and strong coordination and collaboration among the Ministry of Health and Population (MoHP) and external partners. The Global Polio Eradication Initiative (GPEI) has provided the bulk of the funding for this programming, but funds are not siloed, and no distinction is made between polio activities and routine immunisation activities. The notion that individual diseases do not exist in a vacuum is critical to the success of the country's immunisation programming and to the collaborative culture.
• Pro-vaccine messaging through various mediums, tailored to local needs, has generated public awareness. The government is responsible for providing accurate and timely information to the media, and it verifies and corrects messaging as needed. Key informants referenced frequent community-level review meetings to discuss how to address challenges, such as misinformation or poor uptake. Leadership within the lowest administrative levels in Nepal may offer guidance and technical support for community workers adapting messaging or outreach activities. Ultimately, the impetus for adaptations comes from within the communities where workers and volunteers can relate to any cultural, social, and geographical challenges faced by friends, family, and neighbours.
• Public awareness for vaccines has been sustained through extensive community engagement led by the national-level MoHP and implemented through community health workers and volunteers, which supports the community-centred social movement for health in Nepal. Community-based groups meet with district-level health officers to discuss the state of vaccination, challenges, and solutions within their municipality. These community-led groups are involved with immunisation programming, including promotion, service delivery, and targeted outreach. Committees are comprised of members from a variety of religious, ethnic, and socioeconomic groups to connect with hard-to-reach communities and ensure that rumours about vaccines are debunked. Involving diverse stakeholders allowed for tailored messaging and outreach by leaders at the ward or village level depending on contextual factors including culture, religion, and geography. Furthermore, the importance of vaccination is taught to schoolchildren as part of their standard curriculum, with schoolteachers who are mobilised to strengthen immunisation coverage and who get involved in immunisation activities.
• FCHVs educate community members as trusted and compassionate neighbours. They volunteer their time to ensure community members are knowledgeable of their right to receive vaccines, and they engage directly with the communities through door-to-door outreach to parents. FCHVs are required to work in the communities they reside in; mothers report that this generates trust and promotes culturally appropriate messaging. As FCHVs are embedded in the communities where they conduct outreach, their messaging incorporates differences in religion, tribe or caste, ethnicity, and language. FCHVs organise monthly informational meetings with Mothers' Health Groups (MHGs or "Ama Samuha"), which are essential to community peer-to-peer education. The MoHP has emphasised recruiting MHG members from marginalised groups to improve equity, awareness building, and community trust.
• Cultural norms of collective responsibility foster community engagement and ownership of vaccine programming. Empathy is a widely accepted cultural value according to the key informants, and community needs are regarded as more important than individual needs. FGDs with FCHVs revealed that a social obligation to their communities, especially the children, motivated their efforts to increase vaccination coverage.

Reflecting on the research and its findings, the researchers contend that, "Rather than identifying what interventions targeted intent to vaccinate, community demand, and facility readiness, our data support the need to better understand core governance structures and functions with regards to commitment, community ownership, and data transparency and use. Commitment, collaboration, awareness, and collective responsibility at multiple levels of the health system was crucial for the success in Nepal, a finding that applies likely beyond vaccine delivery to the entire health system and suggests the importance of more systemic assessment of health delivery....Though some of the strategies described in this paper may be unique to Nepal, many of the highlighted success factors may have salience in other settings or apply to other health systems for a horizontal approach to healthcare."

In conclusion, Nepal's "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."

Full list of authors, with institutional affiliations:

Kyra A. Hester, Emory University; Zoe Sakas, Emory University; Anna S. Ellis, Emory University; Anindya S. Bose, World Health Organization (WHO); Roopa Darwar, Emory University; Jhalak Gautam, Ministry of Health and Population, Nepal; Chandni Jaishwal, Emory University; Hanleigh James, Emory University; Pinar Keskinocak, Georgia Institute of Technology; Dima Nazzal, Georgia Institute of Technology; Emily Awino Ogutu, Emory University; Katie Rodriguez, Emory University; Francisco Castillo Zunino, Georgia Institute of Technology; Sameer Dixit, Center for Molecular Dynamics; Robert A. Bednarczyk, Emory University; Matthew C. Freeman, Emory University; the Vaccine Exemplars Research Consortium