A Successful National and Multipartner Approach to Increase Immunization Coverage: The Democratic Republic of Congo Mashako Plan 2018-2020

"Rapid improvements were possible in a complex setting through strong partnerships and engagement with national and local partners and simple evidence-based decision-making. Consistent messaging and feedback between the subnational and national levels built engagement and trust from the health facility up to the national level."



There are significant logistical challenges to the implementation of an effective routine immunisation (RI) programme in the Democratic Republic of the Congo (DRC), such as poor use of immunisation data at all levels. In response, the Expanded Programme on Immunization (EPI) within the Ministry of Health (MOH) collaborated with global partners to develop a revitalisation strategy called the Mashako Plan. This plan aimed to rapidly boost childhood immunisation coverage starting in October 2018 with the vision that "routine is the new emergency". This paper describes the plan's implementation, which resulted in short-term improvements in all indicators tracked. The summary below focuses on communication elements of the plan.



To inform the plan, the EPI and partners used available literature, surveys, and administrative data from the District Vaccination Data Management Tool and DHIS2 to conduct a diagnostic review guided by 4 themes, one of which was demand: Interviews with the national, provincial, and health zone programme managers indicated that demand for vaccination services from parents remained strong during RI service delivery, with anecdotal evidence of vaccine refusals only during polio mass vaccination campaigns. Overall, the diagnostic review identified barriers in both service delivery and programme management. The Mashako Plan was developed to remove these barriers using an evidence-based approach with measurable outcomes.



The Mashako Plan aimed to increase full immunisation coverage in children aged 12-23 months by 15 percentage points overall in 9 of 26 provinces within 18 months of implementation. Its 5 key interventions focused on coordination, service delivery, vaccine availability, real-time monitoring, and evaluation. To cite one activity: The Mashako Plan provided training and guidelines on the distribution of vaccination cards to mothers. The national level also improved the distribution of cards to the provinces.



As reported here, it was especially important to ensure that there was support for the plan at all levels of implementation, from the most local level (e.g., vaccinators) to district and provincial management and up to the national level. "The strong collaboration between the DRC government and partners was a critical element in the successful implementation of the Mashako Plan....The strong commitment of MOH staff at all levels combined with partners’ involvement provided pressure on the whole system to improve."



For instance, the rollout of the Mashako Plan featured extensive advocacy and coordination. The EPI programme led the design and implementation of the project and created a steering committee to coordinate all stakeholder collaboration. There was consensus on the need for strong coordination efforts and the importance of shared responsibility between all stakeholders, including national leadership, international stakeholders, and local healthcare counterparts. Use of technology to support immunisation activities, such as a mobile supervision app for systematic supervision, was critical. The real-time monitoring provided a platform for quick evaluation and rapid corrective actions, which enhanced accountability and transparency, allowed for buy-in, and built trust in the system.



To measure progress, the Kinshasa School of Public Health (KSPH) at the University of Kinshasa conducted yearly independent vaccination coverage surveys (VCS). The 2020 KSPH VCS indicated there was a larger increase in coverage in the 9 Mashako Plan provinces than in the 9 non-Mashako Plan provinces when compared to other national surveys. The plan increased RI coverage and key service delivery indicators over the 18-month implementation period, contributing to nearly 360,000 additional children fully vaccinated.



The Mashako Plan is similar to plans that have been implemented in other low- and middle-income countries (LMICs), such as the Mission Indradhanush in India and the Reaching Every District Using Quality Improvement approach in Ethiopia. Like the Mashako Plan, these programmes used local community engagement to improve vaccination rates, especially working to identify unimmunised children. Unlike the Mashako Plan, these strategies did not implement additional national strategies to improve political will to support immunisation programming financially or address other systemic issues.

During a July 2019 forum, representatives from the MOH, EPI, participating province governors, and partners reviewed progress and committed to continuing the efforts to promote vaccination. The President formally committed to full government funding of vaccine purchase commitments in partnership with Gavi, including the amounts for traditional vaccines. The governors committed to actively supporting immunisation in their provinces. The country improved its funding for traditional vaccines, as well as Gavi co-financing, in 2019, 2020, and 2021.



By the end of 2020, 18 provinces had been integrated into the Mashako Plan. In January 2022, indicators were updated in the Mashako Plan 2.0 to account for demand and increase focus on outreach.



In conclusion: "While many of the key indicators showed quick progress, additional efforts are still necessary to reach the full program goals required to improve immunization outcomes. In part, this is achievable by adapting the interventions as the system improves and setting realistic, attainable targets to inspire confidence in the project."