CHWs Close the Immunization Coverage Gap

In partnership with Gavi, the Vaccine Alliance, and the MoHs in Uganda and Kenya, Living Goods has spent the past three years supporting CHWs to close the childhood immunization gap and increase demand, especially in hard-to-reach communities. The urgency of this work has only risen with the onset of COVID, as prior pandemics and epidemics have had a detrimental impact on immunization uptake, and given the promise these learnings will have on driving COVID and malaria vaccine uptake.

Since we launched the experiment in 2018, Living Goods has trained and digitally empowered more than 6,500 CHWs to educate families about childhood vaccines, use their digital tools to track under-immunized children, and make referrals and follow-up visits to ensure all inoculations happen on-schedule. Consequently, there was a shift in health seeking behavior and increased access to vaccines. This resulted in a significant increase in coverage in the areas where we work, with full immunization coverage improving between baseline and endline evaluations by 36% in Uganda (from 50% to 68%) and 69% in Kenya (from 44% to 74%). Zero dose children aged 6 weeks to 59 months—who had never received any vaccines—dropped 87% in Kenya (from 5.2% to 0.7%) and 47% in Uganda (from 13.2% to 7%), meaning that vaccinations have served as an entry point into the health system for children who were previously excluded.

The endline survey also reinforced the impactful role CHWs play in sharing information in their communities. In both countries, more than 80% of caregivers reported receiving information on immunization; CHWs were their primary information source, respectively accounting for 56.3% of touchpoints in Kenya and 41.2% in Uganda. The survey also found that CHWs prioritized immunization follow-ups and education in their household visits, which increased the equity of immunization coverage, bolstered CHW knowledge and skills, and influenced the practices and attitudes of CHWs and caregivers. Key reasons for defaulting included fears of side effects, time constraints for caregivers, other family problems, distance, and transport to health facilities.

Initially, many CHWs did not assess children for immunization during iCCM sick child assessments. A key lesson learned was that CHWs benefited from trainings that integrated immunization and child illnesses from the outset and ensuring that all the relevant workflows were in place on our Smart Health app and spoke to one another. This integration has enabled strong performance in Kenya, where more than 90% of all children under age 2 (U2) have a known immunization status, compared to 65% in Q1 2020. In Uganda, integration of training and app workflows started in Q1 2021, when only 31% of children U2 had a known immunization status. This rose to 74% by September.

While the endline survey shows that community-based immunization promotion contributed to boosting uptake in the areas where we work, other health system challenges remain, including frequent facility-level stockouts and failure to offer immunization services as routinely planned.

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