Advances in childhood immunization in South Africa: where to now? Programme managers, views and evidence from systematic reviews

Thursday, 21st of November 2013 Print
[source]BMC Public Health[|source]

As in many African Countries, EPI in South Africa faces a number of challenges. The vaccination coverage is low, measles outbreaks are frequent and community knowledge of immunization is low.

In this article, the authors conducted an audit to elicit programme managers views of the challenges facing EPI and potential solutions for these challenges. The article concludes with emphasis on the need for partnerships between health policy makers, programme managers, and researchers in order to ensure that health decisions are always informed by the best available evidence. Such a partnership the paper adds is vital to keeping tabs with the ever changing program challenges. More details are available at:


Background: The Expanded Programme on Immunisation (EPI) is one of the most powerful and cost-effective public health programmes to improve child survival. We assessed challenges and enablers for the programme in South Africa, as we approach the 2015 deadline for the Millennium Development Goals.

Methods: Between September 2009 and September 2010 we requested national and provincial EPI managers in South Africa to identify key challenges facing EPI, and to propose appropriate solutions. We collated their responses and searched for systematic reviews on the effectiveness of the proposed solutions; in the Health Systems Evidence, Cochrane Library, and PubMed electronic databases. We screened the search outputs, selected systematic reviews, extracted data, and assessed the quality of included reviews (using AMSTAR) and the quality of the evidence (using GRADE) in duplicate; resolving disagreements by discussion and consensus.

Results: Challenges identified by EPI managers were linked to healthcare workers (insufficient knowledge of vaccines and immunization), the public (anti-immunization rumours and reluctance from parents), and health system (insufficient financial and human resources). Strategies proposed by managers to overcome the challenges include training, supervision, and audit and feedback; strengthening advocacy and social mobilization; and sustainable EPI funding schemes, respectively. The findings from reliable systematic reviews indicate that interactive educational meetings, audit and feedback, and supportive supervision improve healthcare worker performance. Structured and interactive communication tools probably increase parents, understanding of immunization; and reminders and recall, use of community health workers, conditional cash transfers, and mass media interventions probably increase immunization coverage. Finally, a national social health insurance scheme is a potential EPI financing mechanism; however, given the absence of high-quality evidence of effects, its implementation should be pilot-tested and the impacts and costs rigorously monitored.

Conclusion: In line with the Millennium Development Goals, we have to ensure that our children,s right to health, development and survival is respected, protected and promoted. EPI is central to this vision. We found numerous promising strategies for improving EPI performance in South Africa. However, their implementation would need to be tailored to local circumstances and accompanied by high-quality monitoring and evaluation. The strength of our approach comes from having a strong framework for interventions before looking for systematic reviews. Without a framework, we would have been driven by what reviews have been done and what is easily researchable; rather than the values and preferences of key immunization stakeholders.

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