Critical success factors for high routine immunization performance: A case study of Nepal

Abstract

Introduction: The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies drive catalytic improvements in vaccination coverage are not well established. To address this gap, we identified critical success factors that may have led to substantial improvements in routine childhood immunization coverage in Nepal from 2000 through 2019.

Methods: We identified Nepal as an exemplar in the delivery of early childhood immunization through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health post, and community level, we investigated factors that contributed to high and sustained vaccine coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data.

Results: The following success factors emerged: 1) Codification of health as a human right, - along with other vaccine-specific legislation - ensured the stability of vaccination programming; 2) National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building; 3) Pro-vaccine messaging through various mediums, which was tailored to local needs, generated public awareness; 4) Female Community Health Volunteers educated community members as trusted and compassionate neighbors; and 5) Cultural values fostered collective responsibility and community ownership of vaccine coverage.

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

Keywords: CHW, Community Health Worker; Childhood vaccination; DTP1, First dose of diphtheria-tetanus-pertussis containing vaccine; DTP3, Third dose ofdiphtheria-tetanus-pertussis containing vaccine; FCHV, Female Community Health Volunteer; GPEI, Global Polio Eradication Initiative; Health systems strengthening; Implementation research; MHG, Mother's Health Group; MoHP, Ministry of Health and Population; NHEICC, National Health Education Information and Communication Center; NIP, National Immunisation Programme; PEN, Polio Eradication Nepal; VDC, Village Development Committee; VPD, Vaccine Preventable Disease; Vaccine policy; Vaccine programming; WHO-IPD, World Health Organization - Immunization Preventable Diseases.

Fig. 1

A priori conceptual model of the drivers of vaccine coverage.

Fig. 2

WHO UNICEF Estimates of National Immunization Coverage (WUENIC) and Institute of Health Metrics (IHME) DTP1 and DTP3 coverage of Nepal, 2000 – 2019.

Fig. 3

DHS DTP3 coverage of Nepal by Province, 2000 – 2016.

Fig. 4

Immunization coverage with annotated events in Nepal, 2000 – 2019.

Fig. 5

Critical factors that contributed to high coverage of routine vaccinations in Nepal. Arrows adjacent to “Policy & Statute” depict regulatory policies that Nepal operationalized into specific strategies. Arrows adjacent to “Culture” depict more informal attributes that were associated with normative and historical context.