Microplanning: Evidence on Pro-equity Interventions to Improve Immunization Coverage for Zero-dose Children and Missed Communities

"When considering zero-dose populations, microplanning leverages its localized approach to identify and reach missed populations."

This evidence brief, published by FHI 360, seeks to rapidly synthesise existing evidence on the effectiveness and implementation of microplanning to identify and reach vulnerable communities as part of a health campaign or in the context of routine immunisation (RI).   

The brief forms part of a series of rapid literature reviews, conducted by FHI 360 and supported by the Vaccine Alliance (Gavi). The purpose of the reviews is to synthesise existing evidence on the effectiveness and implementation considerations for selected interventions that could help achieve more equitable immunisation coverage, specifically helping to reach zero-dose children (those who have not received a single vaccine to prevent disease) and missed communities (population groups that face multiple deprivations, such as socio-economic inequities and gender-related barriers). Results of syntheses are presented through evidence briefs (see Related Summaries below for others in this series with implications for social change communication) and an online Evidence Map. The objectives of the evidence briefs are to understand which strategies are effective, identify implementation considerations, and assess gaps in knowledge and understanding. Overall, they are meant to help programme planners assess whether an intervention, such as microplanning, should be considered for reaching zero-dose children and missed communities. For this reason, the mapping and the briefs use a categorisation scheme to rate interventions as: potentially ineffective, inconclusive, promising, or proven.

As explained in the brief, "Microplanning is an intervention that bundles planning activities, community engagement, and mapping - among other strategies - at the local level and has been suggested as a critical intervention to identify and research zero-dose children and missed communities." In addition, microplanning "combines the use of coverage and other operational data with population distribution and geography, often using mapping techniques and community input to guide action. The microplanning process is flexible and can be adapted to suit local needs, and it might involve digital and/or non-digital activities, such as creating a district or health center map or identifying priority health centers and communities. In addition to using data, mapping, and community knowledge to identify unreached or under-reached areas, microplans often include technical details relevant to the action plan developed to reach these areas, such as by providing estimates for resources, cold-chain plans, and tools and frameworks for reporting and monitoring."

The literature review, which involved peer-reviewed and grey literature published between January 2010 through November 2022, sought to achieve the following: 
 

1. Evaluate the extent to which current microplanning practices and policies are effective in identifying and/or reaching zero-dose children or missed communities.
2. Identify the main implementation considerations for carrying out microplanning, specific to reaching zero-dose or missed communities.

The following is a summary of the findings as highlighted in the brief:

Effectiveness of microplanning in identifying zero-dose children and missed communities: Based on findings from primary research studies identified in this review, microplanning and enhancements made to existing microplanning processes is deemed "promising". Results from six effectiveness studies found meaningful increases in vaccine coverage or identification of missed communities following the introduction or enhancement of microplanning, often through the addition of digital means. Microplanning also appears to be cost-effective by leading to more efficient use of resources, with some methods being more cost-effective than others. 

The results also showed that microplanning interventions were largely successful in remote rural settings and were often implemented as part of supplementary immunisation activities (SIAs). There is limited evidence on the effectiveness of microplanning for RI. In addition, much of the existing research focuses on innovations to enhance microplanning, and it is inconclusive which enhancements work best in various circumstances and contexts.

Main barriers and facilitators to implementation:
 

• Major facilitators to implementation include community participation, training and supervision of implementers, and the use of geographic information system (GIS) software.
• Major barriers include the lack of accurate population baseline estimates and logistical challenges. These barriers were especially related to accessing communities, whether due to difficult terrain or security issues. 
   

Key gaps: Key gaps include the lack of systematic reviews synthesising existing evidence, lack of studies addressing gender-related barriers, a need for more rigorous studies to assess microplanning independently from other interventions, a lack of studies regarding microplanning in conflict and insecure settings, and wider use of microplanning to reach zero-dose children, as all effectiveness studies were implemented in Nigeria.
 
Due to the research gaps identified in the review, the following recommendations are given as a way forward:  
 

• Given the lack of systematic reviews on microplanning, even outside the scope of immunisation and the overall positive results of individual studies identified in this rapid review, a formal synthesis of current evidence would be beneficial.
• Studies often noted that, because other interventions were implemented concurrently with microplanning, the results presented could be attributable to activities other than microplanning. In addition, the application of microplanning varied widely, and distinctions between activities involved in the microplanning process and other interventions being implemented were often unclear. The lack of clear definitions further complicates the ability to tease out the effects of microplanning from other interventions. Thus, there is a need for more rigorous studies to understand whether microplanning is effective in identifying and/or reaching vulnerable populations. Designing such evaluations will be especially challenging, since microplanning is often implemented in parallel with other strategies. It may be advantageous to conduct studies to assess the effectiveness of specific elements or activities designed to improve the microplanning process, with research questions designed to understand considerations such as effectiveness and cost-effectiveness.
• All effectiveness studies specific to identifying/reaching zero-dose children were implemented in the same country, Nigeria, and involved SIAs conducted among mostly remote rural populations. While this concentration of evidence provides significant depth to understanding the facilitators and barriers in one setting, it limits generalisability to different settings. It would be valuable to bolster evidence within more varied contexts, countries, and uses, including within RI programmes.