Our findings depict an immunization service with an operational level of staff, equipment and procedures in place; but one that reaches just half to two thirds of its target population. The service strengths are similar to, or better than, many other sites in PNG10, and the service deficiencies are similar to those identified for other low- or middle-income settings1. These findings point to a range of immediate opportunities to improve coverage and strengthen local service quality. We discuss these below and, in Table 3, synthesise them into ten recommended actions. By using an evaluation framework based on both PNG’s SIREP strategy and WHO standards, it is possible to relate recommendations to what was included in PNG’s SIREP strategy. Six of our ten proposed actions were already embedded in the SIREP strategy (and hence in national immunization plans), but insufficiently resourced or implemented in our study setting. Particular resource gaps lie in resourcing for outreach. Four actions proposed go beyond the current SIREP strategy.
Table 3: Suggested local actions to improve routine immunization program coverage or quality, and potential contribution of emergency responses or campaigns, in rural Papua New Guinea
Local actions already proposed in the PNG government’s SIREP strategy
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Potential contribution of emergency responses or campaigns
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Local planning based on populations rather than geography
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Campaign coordinators help boost local routine planning capacity
Mapping child populations and data-sharing
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Intensified quarterly outreach focused on higher clinic numbers properly resourced and implemented
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Identify new outreach points, especially with population clusters
Clarify options and costs for transport
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System for tracking unvaccinated children
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Mapping child populations and data-sharing
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Integrated SIAs with additional vaccines, matching local priorities
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Involve district level in planning
Local flexibility in an expanded package of campaign services
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Supportive supervision linked to refresher training including good communications and AEFIs
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Distribute resources to staff
Use campaign monitoring to collect staff priorities for capacity development
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Trained lay health workers (health volunteers) to track births and children, support outreach clinics and promote uptake at static clinics
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Campaign organisation that promotes local involvement
Leverage campaign supports to enlist long-term interest and support
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Local actions that go beyond the PNG government’s SIREP strategy
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Potential contribution of emergency responses or campaigns
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Standardise every opportunity for vaccination, by policy, training and accessibility of vaccine supplies
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Not easily addressed by emergency responses or campaigns
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Health communication products and programs to educate families on the complete vaccine schedule
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Distribute family-oriented communications materials promoting catch-up vaccination
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Test models of integrated services, responsive to community preferences
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Not easily addressed by emergency responses or campaigns
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Review of staff roles and functions to optimise allocations and workload
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Minimise incentives that discourage outreach as part of routine programs
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Note: SIA, Supplementary Immunization Activity. AEFI, Adverse Event Following Immunization.
Options for short-term improvements in existing services
Within current resources, improvements in coverage should be achievable with a fuller implementation of the changes to local service planning envisaged in the SIREP strategy. This recognises that many clinics see few clients (25% with 3 or less), and the fact that most planning is not yet tuned to where most children live. Other persisting gaps in knowledge and capacity that were prime targets of the SIREP strategy include improving catchment population data, increased frequency of service availability, a greater number of outreach points, and quarterly intensification of outreach. Change through improved local planning to reinvigorate outreach has proven successful in settings in Africa and Asia13 that share similar burdens of disease and health system constraints to PNG. In past programmatic research in PNG, alongside the country’s national coverage survey in 200419 similar potential gains were identified. Reinforcement of SIREP training, already well recognised by front-line staff, appears a helpful starting point, but with a stronger commitment of resources to enable more outreach services. Such changes also meet many of the highest priorities expressed by family members in our study.
Our findings also indicate opportunities for increased community engagement and mobilisation; through increased group and individual counselling in the vaccination encounter and the creation and provision attractive, durable, “take-home” information products, aiming to build community demand for a timely, complete schedule of vaccination. Outreach can benefit from stronger, formalised involvement of local leadership, possibly with the deployment of trained lay health workers; such community resources can also help register and track children needing vaccination. Improved session practices, including ensuring managerial and stock support to enable staff to open multi-dose vials even for one child; and the institution of AEFI equipment and periods of observation (which also allows time for education). This mix of enhanced community engagement plus improved local planning has driven routine immunization improvements in difficult settings in sub-Saharan Africa20,21, and vaccination support by trained lay health workers, termed “Village Health Volunteers” in PNG, has been proven in this country in the past22.
Interactions between campaigns and the routine program
PNG’s 2018 polio outbreak has necessitated a major emergency response, with national and sub-national campaigns initially for polio vaccination alone and later with other antigens, particularly measles-rubella, similar to previous SIAs in that country6,23. In Table 3, we have suggested where, based on our findings, emergency responses or campaigns could synergise with the proposed actions to strengthen routine immunization. In other settings, the “micro-planning” used in polio and measles campaigns can inform local service planning13. Such planning was flagged in PNG’s SIREP strategy but not fully implemented in our study site. Sharing of campaign coordination staff and systems to support local managers could help catalyse change by identifying new outreach sites, rebuilding local clinic registers and catchment descriptions, and setting benchmarks for sustainable, practical transport costs. Campaigns and emergency responses could also work for stronger community engagement, including communications with local leaders and trained health volunteers that advocate for long-term support to the continuing routine program. Other practical support could address the planning and information gaps noted in our study, by distributing Child Health Record Books, staff immunization manuals, and other key knowledge resources needed by the routine program.
There is global evidence, especially for measles/rubella SIAs, that they can boost routine programs24; but only if they accommodate the needs of routine immunization in the way they harmonise their planning, invest in suitably generic equipment, share staff and intelligence, use broadly supportive communications, and minimise unsustainable monetary incentives. PNG’s past experience with SIAs suggest they had most success when they maximised district-level control of timing and operations, and of which package of services to integrate25,26.
Longer-term issues
It is clear that changes limited to the front-line are insufficient and central reforms of management, a country-led technical advisory group, procurement and financing, and national re-equipping are also needed and have been repeatedly advised10,11,27; these were largely beyond the scope of our research. Our findings do illuminate the need for new thinking on the immunization workforce; in interviews staff consistently mentioned lack of personnel as an important constraint on extending outreach or integrating new services, in contrast to our observations that staffing was more than adequate for the clinics actually operating. Expanding services will eventually require an expanded cadre of vaccinators, but prior to that our findings suggest a need to expand immunization responsibilities among existing staff, in pursuit of greater efficiency. This could be coupled with the reestablishment of commitment to the national immunization program goals across all staff levels, as one contribution to a revitalisation of immunization professionalism.
One aspiration of the SIREP strategy, and of global immunization programs28, is the greater integration of other services with vaccination; seen to a limited degree in our study by the distribution of vitamin A or albendazole. Our community discussion findings reflect a demand for integration that goes beyond this, prioritising relatively complex services such as maternal illness care, or family planning counselling and provision. These require time and skill that seem difficult within current staffing and infrastructure limits that we have mapped, and would seem to need an integration strategy such as service co-location rather than simply adding tasks to current vaccinators. Testing models to address maternal as well as infant needs through routine contacts in the first year after childbirth, appears profitable and important. If integrated service provision prioritises care that families want, this may help build demand for and confidence in immunization services, as well as meeting their felt needs.
Limitations and strengths
Our sample was restricted to functioning services and families who were willing and able to use those services so our study primarily relates to improving outcomes within existing services. Our data collection took place over the fourth and first quarters of the year, when wet weather events could bias perceptions of access. Despite careful training in unobtrusive observation and non-leading interviewing, there may be some observer effect and/or social acceptability bias affecting the validity of our findings. Single author coding of themes in qualitative analysis increases the risk of bias; our mitigation was to critically reflect on research perspective and carefully cross-check all inferences with local research staff, implementers and policy-makers. Study strengths include the assessment of a representative sample of functioning services, as well as the use of a broad mix of methods and attempt at more detailed interviewing than is the norm in previous service evaluations.