Evaluation of the drivers of urban immunisation in Uganda: a case study of Kampala city 

EVALUATION OBJECTIVES

The evaluation aimed to evaluate the approach of the Uganda National Expanded Programme on Immunization (UNEPI) and partners in providing immunisation services in urban contexts and generate recommendations to inform development of the Uganda urban immunisation strategy.

The evaluation also aimed to generate evidence and learning from the Uganda context that could inform Alliance partners and other country Expanded Programmes on immunization (EPI) on how to best adjust strategies to address the unique characteristics of immunisation in an urban context.

It was conducted in Kampala city between June 2019 and July 2021. The evaluation focused on the drivers of immunisation coverage in Kampala city and the effect of COVID-19 pandemic and its control measures on immunisation service delivery in Kampala city.

METHODS

The evaluation was conducted in two phases. Phase one (June 2019–May 2020) focused on the demand side drivers of immunisation coverage in Kampala, and phase two (June 2020–July 2021) focused on the supply side drivers of immunisation coverage, the effect of COVID-19 pandemic and its control measures on immunisation service delivery in Kampala city.

In phase one, the evaluation used a parallel convergence mixed methods study design. IDRC conducted key informant interviews (KIIs), focus group discussions (FGDs), In-Depth Interviews (IDIs), and a household survey (HHS).

In phase two, the evaluation used a sequential transformative study design. IDRC focused on supply side drivers of immunisation coverage and how the EPI was adapting to immunisation demands in an urban setting. The evaluators conducted KIIs with health service providers, and a health facility assessment (HFA) in 87 health facilities that included 27 observations of immunisation sessions and 238 exit interviews. The HFA identified and measured supply side constraints to vaccination at health facility level. It also sought to understand the effects of the COVID-19 pandemic on immunisation service delivery.

Secondary data analysis and document review were conducted in both phases.

FINDINGS AND CONCLUSIONS

Click the dropdown arrows below to reveal findings and conclusions for each phase of the evaluation.

DOCUMENTS

Drivers of urban immunisation in Uganda - Kampala case study (Phase 1)

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Phase 1

Appreciation of the benefits of immunisation encouraged caregivers to fully vaccinate their children.
The main barriers to vaccination reported by caregivers were: lack of information and misconceptions on immunisation, frequent vaccine stock outs at health facilities, delays at health facilities, competing priorities of caregivers and perceived marginalization of refugees.
EPI model has not sufficiently adapted to the challenges of immunisation in an urban setting.
Uganda National Expanded Program on Immunisation (UNEPI) uses the same approach to deliver immunisation services nationwide. However, this model has suboptimal effectiveness in Kampala city as reflected by high dropout rates, low full immunisation coverage rates, and poor timeliness of immunisation.

Phase 2

Access to immunisation was found to be high, with 96% of infants receiving their first dose of a diphtheria-tetanus-pertussis-containing vaccine (DTP1). However, only 41% of the children were fully immunized, of whom 26.6% were immunized on time.
The main barriers to vaccination included: 1) limited social mobilization and understanding of the importance of full immunisation, 2) vaccine stockouts at health facilities, 3) costs to caregivers, 4) discrimination of minority groups and 5) inadequate client centered immunisation services (i.e. unfavourable frequency and duration of static immunisation services, low numbers of immunisation outreaches conducted and delays at health facilities).
EPI in Kampala is taking steps to adapt to the challenges of immunisation in an urban setting. These steps include: 1) development of an urban immunisation communication plan to guide social mobilization for immunisation in urban settings, 2) revision of the vaccine requisition vouchers to improve vaccine forecasting, 3) allocation of vehicles by MoH to KCCA to support immunisation activities, 4) engagement of the private sector in immunisation services delivery to minimize delays at public health facilities, 5) proposed review of the staffing norms at public health facilities in Kampala so as to address inadequate staffing and 6) leveraging existing partner support to conduct outreach.
The movement restrictions during the lockdown due to the COVID-19 pandemic led to a reduction in the number of children receiving routine vaccination due to challenges in accessing health facilities by both health workers and caregivers.
COVID-19 vaccination has affected routine immunisation in two major ways: 1) it has increased the workload of the already stretched human resources for routine immunisation, and 2) the EPI is focusing more on COVID-19 vaccination than on routine immunisation.
The Uganda National Expanded Program on Immunization (UNEPI) uses the same approach to deliver immunisation services nationwide irrespective of urban-rural differences. However, this model of service delivery is sub-optimal in Kampala city as reflected by high dropout rates, low full immunisation coverage rates, poor timeliness of immunisation and occurrence of measles outbreaks in the period of 2015–2018.
For the evaluation recommendations, please see the full report