Improving Uptake of Routine Immunization in the DRC and Mozambique

Amanda Marr Chung
October 28, 2021
Global Health

When children are not fully vaccinated in the Democratic Republic of the Congo (DRC), the blame is often thrust onto the mothers, who are seen as negligent by program staff. As a mother myself who is keenly aware of the many responsibilities mothers must shoulder, I was baffled by this point of view. However, I was heartened by the work I did this summer on one of the MOMENTUM projects in the DRC and Mozambique with Gobee Group to turn this misconception on its head.

The MOMENTUM Routine Immunization Transformation and Equity project works to build USAID partner countries’ capacity to reduce the number of zero-dose and under-immunized children and to support the rollout of COVID-19 vaccines. As part of the MOMENTUM consortium, Gobee’s role is to lead the co-creation process to address entrenched obstacles to routine immunization. When children do not get immunized, they are at risk of dying from vaccine-preventable diseases. The COVID-19 pandemic has created further disruptions to routine immunization services.

Co-creation refers to the continual, iterative partnership with stakeholders at all levels to understand problems and solutions in new ways, and is embodied by the principles of continuous learning and engagement; sharing power; building empathy; leveraging existing work; listening and adapting; and reflecting and iterating.

The stakeholders within the immunization programs in the DRC and Mozambique include various government actors, such as managers, nurses, and community health workers, as well as the constellation of community actors within this system: caregivers; traditional, political, and religious leaders; neighbors; partners; and other family members.

In order to develop solutions to obstacles to routine immunization in the DRC and Mozambique, diverse perspectives on the root causes to this problem were gathered through in-depth interviews at provincial, health zone, and district levels. These findings were shared with health system stakeholders to build empathy and actively engage in developing user-centered solutions, enabling caregivers (most often mothers) to get their children vaccinated. I was able to dig into the qualitative, in-depth interviews and the development of rapid solutions, synthesizing both of these into solutions cards for inspiration. Some of these solutions will be prototyped, with the goal being to incorporate the most successful solutions into country work plans for implementation.

My review of the interview data revealed that mothers in both countries faced many barriers to getting their children vaccinated: lack of support from their partners; inability to take time off from work; trouble accessing health facilities due to distance, inaccessible roads, and no transportation; punitive treatment by health care workers; misinformation about vaccine side effects; and discouragement by influential community members. Potential solutions to improve routine immunization include: expanding the immunization workforce and vaccination reach and capacity; improving working conditions for nurses and community health workers; involving faith leaders in immunization; leveraging community discussions and connections; and promoting knowledge of and access to vaccination services for mothers (Figures 1-2).


Figure 1. DRC Solutions Card for Parents Who Work in Mines and Fields

Figure 2. DRC Solutions Card for Mothers with Concerns about Vaccine Side Effects

Having worked in global health for over 15 years and most recently with the HIV and malaria programs in Namibia and Zimbabwe, I was struck by the similarity of the challenges that surfaced in the immunization programs in the DRC and Mozambique. First, families struggle to access quality, patient-centered health services provided by health workers who they know and trust in health facilities that are close to their homes. Second, health workers must contend with vehicle and fuel shortages when actively trying to find, test, and treat malaria cases within villages, spray insecticides within homes, and promote and provide HIV prevention services. They also confront suboptimal planning, coordination, and disbursement of the funds to run health activities; administrators suffer from lack of motivation due to not being paid on time, unsupportive supervisors, difficult working conditions, are overburdened with too many responsibilities, which is exacerbated by attrition from public service and the brain drain, and grapple with how to better engage communities to promote health programs and to address misconceptions.

These repeated themes prompt an important question: in order to better ensure equitable health for all, how do we strengthen health systems overall and break down the silos between disparate health programs? One place to start might be to examine the compartmentalized way in which health programs in low-and-middle-income countries are funded. Perhaps external donors might benefit from pausing, reflecting, and examining the entire ecosystem more holistically, putting themselves in the shoes of a patient and how she views the health care system.