Strengthening Immunization Systems in Africa: Insights from UNICEF’s Dr. Paul Ngwakum

Key Takeaways

• COVID-19 disruptions created a large immunity gap and more zero-dose children
• Weak health systems, financing, and workforce constraints reduce coverage
• Urbanization, conflict, and climate change fuel outbreaks of preventable diseases
• Integrating immunization with nutrition and child health increases efficiency and trust
• Data, innovation, and community engagement are essential to finding and reaching missed children
• Domestic financing and partnerships can sustain integrated primary health care

Dr. Paul Ngwakum has worked in many different environments over the past 30 years, from conflict settings to government consulting. As the Regional Health Adviser for UNICEF‘s Eastern and Southern Africa region, he has some ideas for how to move forward — including the best ways to reach children and families who have missed routine vaccinations. 

Over the years, Africa has achieved a lot when it comes to immunization coverage. However, there are still repeated — if not increased — outbreaks across different diseases, including vaccine-preventable ones like measles. From your experience and the work you currently do at UNICEF, what are the main drivers of these increases and what can be done to reverse this? 

There are multiple overlapping drivers. The first one, which I think everybody will agree with, is the disruption of services due to the COVID-19 pandemic. Health facilities were closed. Children were not adequately vaccinated or not even vaccinated at all. And we had this big immunity gap with huge numbers of zero-dose children. So that’s the number one driver. 

The second driver is linked to our weak systems. Weak systems leading to low coverage in vaccination because of insufficient financing, insufficient planning, insufficient human resources, and also the increasing immunity gap. 

We also have other issues: urbanization and people coming to live in urban slums with poor sanitary conditions leading to diseases like typhoid or even cholera. Climate change is also a big driver. We are having changing weather patterns, droughts, floods, cyclones disrupting the ecosystem, and putting populations in precarious situations. 

But above all, on the continent, we are having lots of conflicts — wars, internal conflicts — which lead to displacement of populations, and all this puts them in precarious situations and pushes the increase in these outbreaks. 

In your opinion, what is the best way to approach optimizing services within this current environment?

The first advice I’m going to give is we have to invest in primary health care. We have to ensure that we have strong systems, strong community systems, so that we have an enabling environment to be able to intervene when we have climate challenges and avert erosion of the gains that we’ve accumulated over the years. That’s number one. 

Number two, we have to be intentional about immunization and make sure that we really ensure that we know where these children that have not been vaccinated are and we take the vaccines to them. 

The third point is we have to engage communities. They have to participate, and they have to be part of the decision-making process on how they want to receive these services. We have to use data and innovation to make sure that we know where these children are so that we know exactly how to plan to be able to reach them. Those are some of the few. 

Would you consider looking at integrating immunization with nutrition or other primary health care services, even with campaign approaches or outbreak responses and things like that? 

Absolutely. When you integrate services, you increase acceptance by the population. When a caregiver brings a child for immunization, for example, at the same time that child is weighed, that child is screened for malnutrition, that child receives vitamin A. It’s more efficient and it encourages the caregiver to come back. It’s an opportunity to give integrated services which the child needs. 

These children are almost always of the same age group, less than five years old. And if the child makes his or her way to your caregiving center, I think it’s logical to be able to give this package. 

Sometimes there is resistance in moving away from vertical programs because of the fear that integrating one program with the other will lead to a drop in performance of the other program and factors like that. Are there certain challenges to look out for? 

There are challenges, but these challenges are not insurmountable.  

The first challenge you’re going to meet with is the fragmented setup of these services themselves. If you go to the ministry, for example, you have a different unit dealing with immunization and a different unit dealing with nutrition. They have different reporting lines and even different funding sources and it becomes difficult to bring them together. That’s the number one challenge in integrating services.  

The second one is you have to think about the human resources that are also delivering these services, because a nurse that is trained has capacity to be able to do immunization. When you increase other services — for example, nutrition services — you have to build their capacity and you have to give them the tools to be able to not only deliver but monitor and document.  

Another challenge is the supply chain. Immunization and nutrition have two different supply-chain systems. One needs cold chain. Another one may not need cold chain but has a different distribution system. We have to think about how to harmonize and make sure that we plan in a holistic way to be able to have the supplies we need so that we can easily deliver.  

I think the conversations on the continent are heading in the direction of ensuring that we deliver holistically. I’m thinking about conversations around the Lusaka Agenda, on how we can better manage our different partnerships, bringing government, other stakeholders, and the global health initiatives or donors around the table to be able to support the national health strategic plans. Having one plan, one implementation, one monitoring framework is going to facilitate and reduce these risks of fragmentation and not being able to deliver the services to the child in a holistic way.   

With the current funding landscape, what do you think will ensure the sustainability of this kind of integrated services? 

I think the global challenges that we are having in health care financing is an opportunity for Africa to rethink the way we design our interventions and the way we fund these interventions in general. It’s an opportunity to be able to think about how we can generate resources on the continent, within the countries in the continent, and use those resources efficiently to be able to deliver basic social services for the children, for the continent in general. And I think this is an opportunity to be able to think about how to integrate services, how to deliver immunization, how to deliver nutrition, how to deliver other services using the primary health care platform, which is integrated. That’s number one. 

The second one is talking to governments and the different ministries in the different countries I visit. They’re not thinking about innovative financing, actually. How do they increase fiscal space? You hear things like health insurance. You hear things like targeted resource mobilization or targeted taxation — taxes for beverages, sugar, alcohol, tobacco — that can be used to be able to increase fiscal space for delivering of integrated services. Also, partnerships with the private sector are another opportunity. 

So, I think there is an opportunity for us to think about how Africa can finance the whole system on the continent. And I guess as time goes on, we’ll be able to come out of this crisis better than before.