| Abstract|| |
Context: Although many countries have improved their vaccination coverage in recent years, the Democratic Republic of Congo (DRC) remains with unsatisfactory levels. Aims: The objective of this study is to document the relative importance of the factors that have influenced the immunization coverage in DRC and to understand the extent to which cash support to the DRC by the Global Alliance for Vaccines and Immunisation (GAVI) addresses these issues. Materials and Methods: Data were collected using a modified Delphi and by the analysis of grants and annual progress reports submitted to GAVI. Results and Conclusions: The GAVI health systems strengthening (HSS) proposal is quite strategic. Therefore it should be complementary to other GAVI grants received by the DRC. This is not always so because the different GAVI windows [immunisation services strengthening (ISS), new and underused vaccines, HSS, and civil society support] do not overlap geographically and in the calendar. This is further aggravated by the narrow time horizon of all grants. Apparently, not enough thinking was done at the outset about how the GAVI HSS proposal was going to be implemented. Hence, the acknowledgement by the Delphi panelists that the major barrier to the effectuation of the GAVI HSS grants was in their implementation. The Delphi panel was silent about HR issues but the importance of these issues is captured in the 2006 GAVI HSS grant application. Significant delay in the implementation of the HSS proposal is associated with the lack of a reliable financial management system. GAVI HSS has been catalytic in uniting key stakeholders in the health sector around the HSS strategy, including the DRC government itself.
Keywords: Coverage, Democratic Republic of Congo, GAVI-Alliance, Global health initiatives, Immunization, Vaccination
|How to cite this article:|
Ferrinho P, Dramé M. Barriers to immunization coverage in DRC: An analysis of the GAVI-Alliance cash-based support. Ann Trop Med Public Health 2013;6:401-7
|How to cite this URL:|
Ferrinho P, Dramé M. Barriers to immunization coverage in DRC: An analysis of the GAVI-Alliance cash-based support. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Jan 27];6:401-7. Available from: http://www.atmph.org/text.asp?2013/6/4/401/127773
| Introduction|| |
A fragile state, the Democratic Republic of the Congo (DRC) has been in crisis long before the start of the current conflict in 1998. Well-known levels of maladministration led to economic waning and shrinkage of public revenue, reducing public spending to minimal levels and encouraging their de-regulated privatization. The health-care sector, which in the 1970s had been at the forefront of the primary health care (PHC) movement, bore the full brunt of the crisis, surviving in a fragmented fashion and only because of external support. The uneasy truce established in 2002 has ushered in a slow transition. Nevertheless, peace has remained elusive, particularly in the east of the country, and, despite regular elections, opportunities for democratic opposition are limited. The foundations of a functioning state administration are being laid down and budget allocations to health-care services have expanded from previously negligible levels. More than 70% of the population lives below the poverty line. International partners, including the GAVI-Alliance, are supportive of Congolese efforts. ,,,, Overall, the country is unlikely to achieve most of the Millennium Development Goals by 2015, without strong and sustained economic growth  The Human Development Index of the DRC equals 0.286, resulting in its ranking as 187th among the least developed countries (http://hdrstats.undp.org/en/countries/profiles/COD.html).
The main health-care problems remain malaria, tuberculosis, HIV/AIDS, hepatitis B, diarrheal diseases, acute respiratory infections, malnutrition, and maternal mortality, compounded by frequent outbreaks of diseases such as meningococcal meningitis, polio, measles, and cholera (see also Meningitis Weekly bulletins at http://www.who.int/csr/disease/meningococcal/Bulletin%20Meningite%...). ,,,, The health-care profile is characterized by marked regional and urban-rural asymmetries. ,
In 2000, its health system (HS) was ranked at the bottom of the scale, 189th in 190 countries assessed. 
Currently, the HS is decentralized, with primary care and first referral services integrated within health zones (HZs), each covering approximately 110,000 persons. Above the HZ, the administrative hierarchy includes 26 provinces and the central Ministry of Health (MOH). Due to underfinancing, HZs and facilities have operated with considerable autonomy, with MOH retaining administrative control, and many facilities became de facto privatized, relying on patient fees to pay staff and operating costs. One-third of the facilities are operated by religious groups. Private for-profit providers account for 60% of the provision of services. A number of Global Health Initiatives including GAVI began to support health programs in the early 2000s. The injection of resources into vertical programs further disrupted an already weak sector, with program managers becoming more powerful than MOH directors. Starting in 2004, a group of MOH staff and Congolese health-care advisors working in other agencies began to analyze the problems found within the HS as a whole. Their analysis led to the development of the 2006 Health System Strengthening Strategy (HSSS), which eventually was translated into the GAVI HSS proposal of 2006. ,
Expanded Programme on Immunization (EPI)
The 2005 Global Immunization Vision and Strategy set the goal for all countries to achieve 90% national diphtheria-tetanus-pertussis (DTP3) coverage by 2010. However, in 2010, 19.3 million children were not fully vaccinated; approximately 50% of these lived in India, Nigeria, and the DRC. 
In 1988, the World Health Assembly voted for the global eradication of polio. After freedom from polio since 2004, polio re-entered the DRC from Nigeria in 2006. ,,, Of all the countries in Africa, the DRC and Nigeria are also reported to still have the highest average annual incidence and mortality associated with measles. ,,
Since its inception in 1978 until 1990, the EPI in DRC, with the support of bilateral co-operation, managed to achieve significant progress in vaccination coverage for six vaccine-preventable diseases-tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis, and measles. After the yellow fever vaccine was introduced in 2003, the DRC further expanded the spectrum of vaccines by introducing viral hepatitis B vaccine (2007). In its 2008-2012 multiyear plan, the country proposed to introduce Haemophilus influenzae type b vaccine in 2009 and pneumococcal vaccines in 2010. The introduction of rotavirus will happen in 2013. One of the major bottlenecks in expanding the range of antigens covered by EPI is associated with the storage capacity at national and provincial levels.
Despite the war, since 1998, vaccination activities restarted in majority of the health centers, linked to the renewal of the cold chains and training and supervision of staff and to the establishment of supplemental immunization activities (SIA) to complement the lack of reach of fixed vaccination points. ,,,,,
Since the first multiple indicators clusters survey (MICS1) in 1995, when the DTP3 coverage for children aged 12 to 23 months was 27 coverage increased to 46 to 57% as documented by MICS2 in 2001 and MICS3 in 2009, (http://www.who.int/vaccines/globalsummary/immunization/countryprofileselect.cfm) [Figure 1].  From 2008, there have been discrepancies between the official country estimates of DTP3 and the estimates of the World Health Organization (WHO)/the United Nations Children's Fund (UNICEF).
Funding of EPI
In 2009, total health expenditure (THE) per capita was USD 3.3; government health expenditure as a percentage of THE was 23.9%; official development assistance for health (ODAH) was about USD 4.8 per capita and 13.1% of ODA to the country; the five largest sources of ODAH (representing 72% of all ODAH) were the Global Fund for Tuberculosis, AIDS and Malaria (19%), the governments of the United States (16%), Belgium (14%), and the United Kingdom (10%), and GAVI (12%). 
GAVI has been assisting the government in immunization and health-care development since 2002 with immunisation services support (ISS 2002-2008), injection safety support (INS 2003-2005), health systems strengthening support (HSS 2008-2013), tetravalent vaccine support (2007-2008), pentavalent vaccine support (2008-2012), pneumococcal vaccine support (2011-2012), yellow fever vaccine support (2003-2012), and civil society organizations (CSO) support type A (2008) and B (2008-2009). The government has not been able to honor its EPI cofunding commitments.
Considering the relative standing of the GAVI-Alliance cash-based funds in sustaining vaccination services, it was decided to document the importance of factors (in particular HSS grant related) that might explain the inability of the DRC in achieving a DTP3 coverage of 90% by 2010, despite the support of GAVI.
Population and Methods
The study is based on a modified Delphi and on the content analysis of documents found in the country hub for DRC of the GAVI Alliance in March 2012.
A modified three-round Delphi study was carried out during November 2011. Qualitative data was concurrently collected throughout the different rounds, mostly in an unstructured way. Panelists were asked to quantify as a percentage the relative contribution of five tentative causes (total of the five causes should add up to 100%):
- Design failure (inappropriate design of the HSS/ISS proposals)
- Implementation failure (bad implementation due to capacity constraints, changes in plan, and so on)
- Inadequate governance of the grant (administrative delays, leakage, and so on)
- Insufficient size of the funds made available through the HSS/ISS proposal and/or lack of complementary funding
- External factors, exogenous to the health sector (civil war, disasters, and so on).
Country work was in Kinshasa by an external WHO consultant supported by the WHO country office and the MOH, who assisted with the recruitment of local experts for the panel. Round 1 was by e-mail on November 2, 2011. The panel met on November 3 for rounds 2-3. The consultant facilitated the rounds and associated discussions, calculated means, medians, modes and ranges for the results of round 1 and asked the panellists for re-estimates for rounds two and three, confronting them with the summary results of previous rounds to move them, without coercion, toward a consensus position on the estimates. Consensus was considered when the distance between the median and the average was less than two percentual points or for any range of values that included 75% of the replies [Table 1].
The documents analysed were ISS/new and underused vaccines and injection safety annual progress report (APR) from 2005 to 2008, the 2006 HSS grant submission and 2008 APR, the 2007 CSO type B support and the respective 2008 APR, the 2007 application for the introduction of vaccines for H. influenzae type B, and the 2008 application for the introduction of pneumococcus vaccines.
The analysis was similar to the one described in the literature.  It was based on the HS building blocks of the WHO-service delivery, health workforce, health information systems and monitoring and evaluation (MandE), logistics (infrastructures, medical products, vaccines, and technology), financing, and leadership and governance.  This was extended to classify activities as downstream or upstream. Downstream activities were those that one would reasonably assume exist at the district health-care system level or below and not involving comprehensive change at a higher, systemic level. Upstream interventions were those taking place at and/or involving change (action or resources) at a level higher than the district. Where an intervention could be considered systemic and operational, it was classified as systemic. No one building block was considered to be uniquely systemic or operational. These were complemented by an additional category, community orientation. ,
| Results|| |
After applying the different definitions of consensus to the data from the last round, a range of possible consensus values was obtained [Table 2]. The lowest value of the narrowest range of values for a specific factor was adopted as the consensus estimate [Table 3].
|Table 2: Range of consensus values (%) according to different definitions of consensus|
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Implementation and governance factors were perceived as the major issues hampering the HSS grant potential to improve vaccination coverage. These perceptions were further strengthened with the qualitative data [Table 4].
|Table 4: Qualitative data from rounds 2 to 3: Reasons behind the performance factors|
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The data in this table [Table 4] reflect passionate discussions among the participants. The discussions focused very much on implementation problems and governance issues (mechanisms of resource allocation and management procedures).
Implementation was vehemently felt by some to be a very important issue, not being properly addressed. External factors (context) were also perceived as an excuse not to do what needs to be done rather than being the 'real problem'.
The problems of financial management, considered highly significant, were discussed under governance (at the periphery, there are no mechanisms for the production, verification, and transfer of the expenditure receipts) and under external factors (the frailty of the banking system where GAVI funds are deposited). Other than for salaries, cash transfers are not allowed in the Congolese public administration; hence, the problems encountered with the lack of established procedures to trace and control expenditure of the cash transferred delayed the start of implementation.
The issue of conceptualization was raised by the representatives of the CSO. The three GAVI windows (ISS, HSS, and civil society support) did not overlap geographically and in calendar, making resources for vaccines available out of synchrony with resources for CSO and HSS interventions. This was aggravated by the narrow time frame of 2-3 years for each GAVI window.
Although not openly addressed in the Delphi questions, the whole issue of logistics was acknowledged in the discussions as a major bottleneck.
The final discussion on consensus recommendations to the Board of the GAVI-Alliance flowed from the qualitative data [Table 5].
Results of document analysis
The focus of the barriers identified in grant APR for ISS/new and underused vaccines/injection safety has been upstream rather than downstream (at both levels, the focus was on logistical and financing system barriers). But, as expected considering the nature of the grants, the interventions-without neglecting upstream activities (focused on leadership and governance, workforce issues, and financing system strengthening)-focused on downstream activities with a major concentration on logistics, health-care information and MandE, and the workforce (mostly training). The key groups of barriers reported are associated with leadership and governance and funding [Table 6].
|Table 6: Activities proposed in the GAVI HSS grant according to building blocks and to their upstream/downstream nature|
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The HSS cash grant application is ambitious in the identification of, mostly, upstream barriers (leadership and governance and workforce issues) with the proposed interventions focused upstream on governance, logistics, health-care information and MandE, and the workforce (less focused on training), and downstream on logistics and maintenance, leadership and governance, and the health-care workforce. The APR for the first year of grant implementation was hampered by financial system barriers and focused on establishing downstream governance mechanisms [Table 6].
With the exception of the application of the CSO type B support, all documents analyzed are blind to barriers and activities oriented for community mobilization and promotion of demand [Table 6].
| Discussion and Conclusions|| |
The HSSS and GAVI HSS are strategic in outlook and orientation, with a vision of the results needed for strengthening the HS and are in line with the DRC poverty reduction strategy. Hence they should be complementary to other GAVI grants. This is not always so because the different GAVI windows do not overlap geographically and in calendar. This is further aggravated by the narrow time horizon. The difficulty in considering interventions targeting sustainable results with narrow horizons echoes Jeffrey Sachs: "It's not a year or two of help that we need, but it's 20 years of help". 
Apparently, not enough thinking was done at the outset about how either the HSSS or the GAVI HSS proposals were going to be implemented.  Hence, the acknowledgement by the Delphi panelists that the major barrier to the effectuation of the GAVI HSS grants was in implementation [Table 2],[Table 3],[Table 4] and [Table 5]. However, implementation has to do with many of the facets inquired about during the Delphi: Conceptualization of the proposal, governance of the grant, availability of funds , articulation with other grants and funds, external factors, and so on. Implementation is further hampered by inadequate administrative systems which, as for other fragile states, perform better centrally than at the periphery creating problems as "national elites, … short on technical knowledge of how to specify and administer what is needed in globally acceptable terms, will tend to adopt procedural short cuts or observe practices downstream - in certification, payments and reporting - which … draw the ire of their international partners concerned with fiduciary risk and corruption". 
The Delphi panel was silent about workforce issues. This probably reflects that these are still perceived as 'too politically sensitive to tackle in the open'.  However, during an evaluation in 2009, there was agreement that reform in workforce was vital to the successful implementation of any HSSS.  The importance of workforce issues is captured in the GAVI HSS application, in the barriers identified and activities proposed: Workforce-related actions account for 32% of the budget. The workforce development package includes training, the reform of health sciences education, and salary supplements for an improved redeployment. , The DRC also allocated 15% of its ISS funding for a performance-based bonus system for EPI staff at all levels, including managers.  The GAVI-Alliance funds performance-based remuneration without any clear indication of how this is to be sustained or absorbed into improved salaries and incentives more generally. ,
One area that has caused significant delay in implementation of the HSS proposal is the setting up of a financial management agency. The tendering, selection, and contracting of the agency has taken far longer than the government expected, delaying an analysis study of the situation in each of the target HZs.  This is acknowledged by the Delphi panelists as one of the major stumbling blocks to the implementation of the GAVI HSS.
Several evaluations have shown that vaccination coverage increases with the level of wealth and the degree of education of the mother. It is usually highest in urban populations, in Kinshasa and in Bas-Congo and particularly low in Maniema, Equateur, and Orientale Province. Operational factors associated with low coverage include: (i) Inadequate communication with the mother who does not know about follow-up doses, (ii) obstreperous staff attitudes, (iii) stock-outs of vaccines, (iv) unpaid salaries leading to demotivation, and (v) the opportunity cost of coming for vaccines in a context of generalized poverty. , As such, it is surprising that most GAVI proposals and APR do not touch on mobilization of the community to enhance the demand for vaccination services. This issue was also ignored by the Delphi panelists. The exception was the CSO type B support proposal that identified a range of activities to mobilize the community. This neglect may reflect the fact that the effectiveness and cost-effectiveness of efforts to increase demand are still uncertain. 
The discrepancies between official country estimates of DTP3 and those of the WHO/UNICEF are recognized. Country estimates usually mimic estimates of the WHO/UNICEF at a higher level. , Data problems were also identified in several data quality assessments.  If HZ data are to be used in monitoring and planning immunization programs as intended by decentralization, heterogeneity in their validity must be reduced.  Therefore, it is quite appropriate that health-care information issues are emphasized in most APRs and proposals, although not acknowledged by the Delphi.
GAVI HSS activities will be monitored using the National Health Information System framework. This "may be missing some of the critical contributions" that the grant could be making to the HS, namely "a) increased alignment and harmonisation of all partners with the national HSS strategy; and b) the effective functioning of governance and accountability mechanisms that support the implementation of the HSS strategy. In this, GAVI HSS has been catalytic in uniting key stakeholders in the health sector around the HSSS, including the DRC government itself". 
In the DRC, slow progress in vaccination is aggravated by several contextual barriers: The size of the country, an ongoing civil war, the shortage of infrastructure, and so on. This situation epitomizes Calain's resource curse theory  of a country rich in natural resources where the burden of poverty weighs heavily. This underlies many of the social tensions that contribute to vaccination coverage below the expected target. The results gained so far give hope to the DRC and to other countries in similar conditions. It is important that gains in vaccination are shrouded in initiatives that consolidate those gains into sustainable strengths of the health-care system. The GAVI-Alliance is helping, but the short horizon of its grants is a major barrier to long-term gains.
| Acknowledgment|| |
The authors are grateful to Rosa Bela Ferrinho for support in the preparation of the draft for publication.
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Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Rua da Junqueira 100, Lisbon
Source of Support: WHO, Geneva, Conflict of Interest: The Instituto de Higiene e Medicina Tropical is a collaborating center of the
WHO. One of the authors is a staff member of the WHO. This work was funded by the WHO.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]