In 2019, the Alliance for Health Policy and Systems Research joined forces with Ethiopia’s Federal Ministry of Health and the University of Gondar – the oldest medical school in the country – in a unique collaboration to tackle a major threat to global health and development: poor immunization coverage.
Funded by Gavi, the Vaccine Alliance, and in partnership with United Nations Children’s Fund (UNICEF), the goal of the initiative was to identify key immunization programming issues and support attempts to solve them, while also mitigating wider system barriers if possible. An approach called embedded implementation research was used, which establishes early and sustained collaboration between researchers, implementers and policy-makers to ensure that studies are relevant and recommendations feasible.
In Ethiopia, immunization services are an integral part of primary health care, delivered in all public health facilities across the country. But achieving and maintaining coverage has proved challenging with full national coverage currently stalling at just over 40% – well below global targets. A range of implementation barriers are to blame, many of which relate to the way services are planned and delivered.
This joint initiative strengthened the capacity of key stakeholders to define research questions together and carry out and use research findings. In many cases, this involved planners and programme managers co-producing data with researchers and then discussing its applicability in specific settings. A local technical support centre, housed within the University of Gondar, helped ensure the day-to-day management and quality assurance of studies.
A new special issue of the Ethiopian Journal of Health Development showcases the research findings from a number of these studies, with an editorial from the lead partners reflecting on the role embedded implementation research can play in strengthening efforts towards improving primary health care.
The 12 research articles explore a range of challenges and bottlenecks, and they identify and test strategies to address immunization service delivery constraints. Better linking communities with relevant health facilities to ensure more responsive immunization services is discussed, as is the urgent need to adapt immunization strategies to reach urban populations, or the use of social and behavioural change communication to increase trust and confidence in vaccines. The challenges of displacement into temporary settlements, loss of health service infrastructure and the shortage of trained health workers following conflict is also explored, as are chronic systemic problems including vaccine supply and cold chain management issues, as well as inadequate data capture and management. Finally, vaccine safety practices, data quality, gender and determinants of immunization coverage are considered.
Through significant coordination and ongoing engagement, the initiative helped cement partnerships between immunization policy-makers and researchers, which enabled them to address challenges and produce learning that can inform the country’s new Health Sector Transformation Plan. This foundational work is expected to provide the intelligence needed to respond, adapt and improve programmes, and to be instrumental in promoting cultures and practices of learning within local health systems.
This special issue complements two other special issues that came out in 2021 from the Alliance focusing on embedded research: the Decision-maker-led implementation research on immunization supplement of Health Research Policy and Systems and the Embedded implementation research for the Sustainable Development Goals special issue of the Pan American Journal of Public Health. Taken together, these publications are carefully documenting the evolving nature of this approach to research including innovations in the methods, approaches and governance of research on public health policies and programmes in low- and middle-income countries.