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Zambia is a landlocked country in Southern Africa with an estimated 2009 population of 12, 939,233 million. The country is divided into 9 provinces and 72 districts.
The EPI programme immunization in Zambia commenced in 1975, and in 1984 the Ministry of Health adopted the goal of universal childhood immunization. All children up to 5 years are eligible for vaccination. However, the priority is to vaccinate all children with all doses of available antigens before the first birthday.
Zambia submitted its application to GAVI for pentavalent vaccine in 2001. Following the approval, GAVI committed itself to supplying the pentavalent vaccine in third quarter of 2002 but this was later changed to the third quarter of 2003 due to vaccine production failure. Following consultations with the GAVI Vaccine Provision Project, implemented by UNICEF, WHO and the Vaccine Fund, the Ministry of Health decided in January 2003, to introduce liquid-lyophilised tetravalent, DTP+Hib in January 2004 and switch to liquid-lyophilised pentavalent, DTP-HepB+Hib in 2005. Following the availability of the fully liquid formulation late in 2006, the country eventually switched to the fully liquid formulation from February 2007.
Routine immunization coverage has generally been high. Some of the key activities that could have contributed to this achievement include the training staff at all levels on EPI in 2002, the first in 10 years. This was followed by introduction of the Reaching Every District (RED) approach in pilot districts in 2003, and training on the Hib vaccine in 2003. By 2008, all 72 districts had started implementing RED and supportive supervision was intensified.
The quality of the routine immunization coverage data was confirmed by an external Data Quality Audit (DQA) commissioned by GAVI in 2003, in which Zambia achieved a verification factor of 0.79 and received awards for increasing routine coverage in subsequent years, particularly DTP3 coverage among children under the age of one.
A post introduction evaluation (PIE) is recommended by WHO for all countries that have introduced a new vaccine. Ideally, a PIE should be conducted within 6-12 months of introduction, (a) to allow enough time for programme scale up, collect data and develop potential long-lasting problems due to introduction, and (b) early enough to correct any major problems related to the introduction. The PIE for Zambia was conducted two years after the switch from liquid-lyophilised to fully liquid pentavalent.
Prior to arrival, eight Districts within four Provinces were selected based on the level of performance, to include good, medium and poor performing Districts and to obtain geographical spread throughout the country. Within each District, 3 HFs were chosen, also based on high and low performance, resulting in the total selection of 24 HFs. The evaluation group was divided into four teams to visit the eight Districts; the teams comprised one external evaluator and two national evaluators. Each of the four teams evaluated one Province and two Districts. The Districts selected were Lusaka, Chongwe, Ndola, Masaiti, Mansa, Mwense, Mumbwa and Kabwe. The teams visited the Province and District Health Offices, as well as three HFs per District. The HFs were selected, in consultation with District staff, based on their EPI performance. The cold stores at National, District and HFs level were also evaluated. Mothers were interviewed and observations were made during immunization sessions in the HFs. In total, 24 HFs were visited during the 5-day field data-collection trip.
Findings and Conclusions:
Pre-implementation planning and training
Early and effective planning is essential prior to introduction of new vaccines. As the introduction of new vaccines has implications on the vaccination schedule, cold chain capacity, distribution plans, training of health workers and key messages for community acceptance, there is need for the country to prepare adequately. Zambia, with the support from the Interagency Coordinating Committee (ICC), made the decision to switch from the lyophilised DPT-HepB+Hib vaccine (pentavalent) to the liquid one dose DPT-HepB-Hib vaccine in 2006. The Child health Technical working group in collaboration with partners assessed the feasibility to undertake the switch and developed a plan to facilitate a smooth transition. Training guidelines were prepared to facilitate cascade training of health workers at provincial, district and health facility levels early 2007. Funding was sourced from UNICEF, and MoH basket funds.
The Child Health Technical working group developed a detailed national plan for the switch in vaccine presentations with guidance from the ICC. Subsequently cascade trainings were conducted to orient health workers on the switch prior to vaccine introduction. Participants at the trainings were provided with handouts and CDs containing information on the liquid pentavalent. The national level supported the provincial and district trainings.
The provincial and district staff were advised to allow the remaining stocks of the DPT-HepB+Hib to be fully exhausted before switching to the liquid formulation. Consistent instructions were given to health workers for continuation of the liquid vaccine for subsequent doses. This ensured smooth introduction of the liquid pentavalent vaccine. Health Facilities did not report any interruption of immunization services as there was no gap between arrival of the liquid pentavalent vaccine and phasing out of excess lyophilised pentavalent vaccine. 96% of health facilities visited reported a smooth transition to liquid pentavalent.
Areas for Improvement
Even though there was a national plan for introducing the liquid pentavalent vaccine, district-specific plans with concrete activities and timelines for implementation were not evident at the lower levels. There was minimal training on the switch because more training was done for the lyophilized vaccine. Training on the switch was not provided to all relevant staff members of the Health Facilities and those staff members trained had to subsequently train the rest of the Health Facilities. Training manuals were not readily available at the sites and not all members of the health facilities were trained.
The plan for continuation in the use of the remaining lyophilized DPT-Hib-HepB stock was conveyed verbally, and not through a written plan. A written plan provides information for health workers document how the transition from lyophilized pentavalent to the liquid formulation would take place
Adequate training materials should be developed and distributed to all health facilities for future new vaccine introductions or programmatic changes
Adequate resources should be mobilized for pre-implementation training of a large number of health workers on new vaccine
For future introductions, District specific plans should be developed clearly highlighting how the switch to new vaccine would be undertaken.
Future new vaccine introductions or programmatic changes should utilize a chronogram of pre-introduction activities that is distributed as a template to all levels in advance. County-specific planned activities should be reviewed by the national team with the Partners prior to initiating the introduction activities.
A clear, written policy regarding the procedure for existing vaccine stocks should be prepared and communicated to HCWs at all levels.
Training should be provided to a broader audience at the Health Facility level.
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