A Toolkit for Engaging Non-Health Stakeholders in Supporting Routine Immunization in Uganda

"When actively engaged by their local counterparts in the health system, these [non-health-stakeholder] individuals have demonstrated that they play unique and vital roles that improve the reach, provision, and utilization of immunization services, thereby improving the health of communities."

To help strengthen the routine immunisation (RI) system in Uganda, JSI Research and Training Institute, Inc. (JSI) has been working since 2012 to support the Ministry of Health and Uganda National Expanded Programme on Immunization (MOH/UNEPI). In doing this work - through the Stronger Systems for Routine Immunization (SS4RI), Maternal and Child Survival Program (MCSP, 2014-2019), and the Maternal and Child Health Integrated Program (MCHIP, 2012-2014) projects - JSI has learned that non-health stakeholders (NHS) must be engaged and empowered at district, sub-district, and community levels in order to improve immunisation services and create ownership of the programme on a sustained basis. This toolkit consolidates JSI's learning in engaging NHS.

NHS for immunisation are all the personnel and offices needed to reach every child, wherever they are, with high-quality immunisation services. In Uganda, JSI has found that they include, in broad terms:

• District and sub-county political, civic, and administrative leaders;
• Religious and cultural leaders;
• Parish chiefs, Local Council 1 (LC1) leaders; and
• Village Health Team members (VHTs).

A few of the reasons JSI has identified for actively engaging these NHS include:

• As important social influencers, NHS and political, religious, and cultural leaders can mobilise their constituents to make use of immunisation services.
• NHS can identify root causes of immunisation challenges that are sometimes missed by health personnel themselves - particularly if the responsibility for the problems lies with health worker practices.
• Because NHS work on a range of civic issues, they can identify and address other areas (e.g., transport, roads, and finances) that directly or indirectly affect immunisation services.
• The participation of NHS in processes related to health has uncovered additional opportunities that can be tapped to supplement government efforts, thereby increasing self-reliance and ownership for immunisation within the district.

Some communication-centred examples illustrating how the engagement of NHS has registered tangible impacts toward improving RI in Uganda include:

• Some district heads (Residence District Commissioners [RDC]) provided airtime on local radio stations so that health workers could educate communities on the importance and timing of RI services.
• RDCs have engaged with vaccine-hesitant communities to encourage their use of vaccination services.
• Religious leaders and politicians have provided time to health workers for sharing key messages on RI at public gatherings such as church sermons, burials, and weddings.

In this context, the toolkit applies concepts and methods from the field of quality improvement (QI) to the Reaching Every Community/Child (REC) approach already adopted by the MOH/UNEPI. (See the below video for details.) This enhanced approach builds the managerial capacity of national, district, and health facility teams to diagnose and prioritise problems affecting immunisation service delivery and utilisation, identify their root causes, and introduce and test solutions using Plan-Do-Study Act (PDSA) cycles.

The toolkit presents step-by-step guidance that district health teams (DHTs), district leaders, MOH/UNEPI, immunisation partners, and civil society organisations (CSOs) can use to engage NHS and maximise the benefits of their participation in strengthening RI through activities such as community dialogue meetings. Tables and annexes outline this process and include, for example:

• Annex 1: RED [Reaching Every District] Categorization Tool
• Annex 2: Equity Assessment Tool
• Annex 3: Sample Supervision Guide for NHS
• Annex 4: Monthly Reporting Format by Health Facility
• Annex 5: Sample Agenda for Monthly Health Facility Staff Meetings
• Annex 6: Costing the Engagement of NHS
• Annex 7: District Leaders Commitments to Support NHS in Uganda

Principles stressed throughout the resource for the engagement of NHS include: transparency, collective problem solving, a spirit of ownership, commitment to changing the status quo, and realisation that every actor has a role to play.