Success in vaccination programming through community health workers: A case study of Nepal, Senegal, and Zambia

IntroductionCommunity health workers are essential to frontline health outreach throughout low- and middle-income countries, including programming for early childhood immunization. The World Health Organization estimates a projected shortage of 18 million health workers by 2030. Understanding how community health workers are engaged for successful early childhood vaccination among countries who showed success in immunization coverage would support evidence-based policy guidance across contexts. To that end, we identified factors of community health worker programs that contributed to improved vaccination coverage in Nepal, Senegal, and Zambia. MethodsWe conducted interviews and focus group discussions at the national, regional, district, health facility, and community levels of the health systems of Nepal, Senegal, and Zambia, and used thematic analysis to investigate contributing factors of community health worker programming that supported early childhood immunization within each country and across contexts. We developed a model that could be used for assessment and adaptation based on lessons learned. FindingsAcross all countries, implementation of vaccination programming relied principally on the 1) organization, 2) motivation, and 3) trust of community health workers. Organization was accomplished by expanding cadres of community health workers to carry out their roles and responsibilities related to vaccination. Motivation of community health workers was supported by intrinsic and extrinsic incentives. Trust was expressed by communities due to community health worker respect and value placed on work. ConclusionImprovements in immunization coverage followed successful community health worker programs, facilitated by diversification of cadres, roles and responsibilities, motivation, and trust. With the continued projection of health worker shortages, especially in low-income countries, community health workers bridged the equity gap in access to vaccination services by enabling wider reach to minority populations and populations in hard-to-reach areas. Although improvements in vaccination programming were seen in all three countries - including government - commitment to addressing human resource deficits, training and renumeration; workload, low and inconsistent compensation, inconsistency in training duration and scope, and supervision are still major challenges to immunization programming. Vaccination and health decision-makers should consider organization, motivation, and trust of community health workers to improve the implementation of immunization programming.