Lessons for Strengthening Childhood Immunization in Low- and Middle-Income Countries from a Successful Public-Private Partnership in Rural Nigeria

"...foster ongoing community-engaged strategies to facilitate program success..."

A number of individual, family, community, and health-system factors contribute to low immunisation coverage in Nigeria. This paper describes a public-private partnership, supported by corporate social responsibility (CSR), which administered a childhood immunisation programme in rural Sabongidda-Ora, Nigeria, from 1998 to 2015. The goal was to provide free, comprehensive immunisation services for children without routine access until government-sponsored services were made available. The paper summarises key steps in the programme development and highlights lessons learned, which may inform the development of future CSR-driven partnerships for health services and the scaling up of novel vaccines.

To assess the need for a vaccination intervention in Sabongidda-Ora, the researchers conducted a needs assessment informed by in-depth interviews with: (i) community representatives in the church and local government (n=10); (ii) medical directors at the healthcare facilities in the community (n=3); and (iii) mothers (n=52) of children aged under 5 years. This assessment revealed that community members had been well educated on the expanded programme on immunisation (EPI) and that mothers were very interested in immunising their children, but the availability of immunisations was poor. This focus was a strategic fit for GlaxoSmithKline Biologicals (GSKBio).

The project's community-engaged approach included outreach to leaders across several community layers. Multiple consultations were organised to galvanise alignment with the traditional rulers of Sabongidda-Ora first, and subsequently with the six neighbouring communities. In their capacity as key influencers, the traditional rulers helped create awareness of the new programme and encouraged mothers to receive vaccination for their babies. Further consultations led to engagement by the local government authority (LGA) and the Edo State Ministry of Health, which "fostered a collaborative and supportive relationship with stakeholders who represented a community advisory board that advised on pre-implementation, facilitated recruitment and provided ongoing program support. Involvement of the local, state and federal health authorities was critical for the development of a transition plan that was articulated very early in the planning process." The researchers then assembled a multidisciplinary team that had expertise in public health nursing, family medicine, vaccinology, and pharmaceutical medicine. Several team members were also community members: "Their knowledge of local tradition and culture, combined with their commitment to the health of the community, were very helpful in maximizing program delivery", as reported here.

Vaccines were provided thrice weekly at a clinic that served an average of 150 children monthly. The researchers engaged programme staff, community leaders, and key informants as local experts, and they worked to respond to the needs they raised about programme services. Based on their feedback, in addition to comprehensive vaccine services, the programme provided basic health and hygiene education to young mothers, both at the programme facility and through outreach to nearby communities. For example, vaccine days started with health education talks, weight checking, growth monitoring and nutrition lessons. Once the centre began to offer routine childhood immunisation services (in addition to inpatient and outpatient care), patients were counseled about the transition process and referred to the new centre with updated immunisation cards. Programme equipment and supplies were donated to the new primary healthcare centre, and the programme was dissolved.

Data provided in the article indicate that the programme was associated with a 30-fold increased chance of complete, age-appropriate vaccination relative to other programmes in the community. Traditional rulers of the Sabongidda-Ora community relayed an outcome they considered important: "Ai ki che h'owa oimi fieo a", they said in the local language, Ora ("no more look away, an infant corpse is approaching the grave"). Community observations were consistent with the published literature on the estimated mortality impact of childhood vaccinations. For instance, a GAVI report suggests that routine hepatitis B vaccine (HBV) alone, a vaccine that was newly introduced into the community under this programme, averts an estimated 8.3 deaths per 1,000 persons vaccinated.

Reflecting on the experience, the researchers point to key basic principles: conducting a comprehensive needs assessment, collaboratively engaging with the community, identifying strategies that would meaningfully address implementation outcomes, and developing a plan for programme maintenance and, ultimately, transition. For example: "The community engagement continuum describes five steps of increasing engagement, which have been shown to positively impact research partnerships in general and immunization programs in particular. The steps consist of outreach, consultation, involvement, collaboration and shared leadership. Community engagement was a fundamental pillar in the GSKBio Vaccination Program even before it was a named methodologic approach. Indeed, a community engagement approach will be critical to the successful adoption of new vaccine programs, including the present-day roll-out of the SARS-CoV-2 vaccine."

There were some challenges, such as port customs clearance issues that sometimes caused substantial delivery delays in importing the vaccines from Belgium through Lagos. The programme team and the community collaborators reportedly anticipated such challenges and thus were able to identify strategies to address them (e.g., arranging to receive interim supplies from GSKBio's country office inventory in Lagos and occasionally from local government supplies).

In conclusion: "The project was developed and administered within a strategy encompassing evidence-based goal-setting, building of purposeful collaboration, resource mobilization and measuring performance and impact....[T]he project also demonstrated key principles of community engagement and implementation science while leveraging a CSR initiative from GSKBio, which also fueled its success. The project delivered its major goals, including raising childhood vaccination rates, contributing to public health research and the transfer of services to a newly constructed government facility."