Integrating COVID-19 and Routine Immunization in The Democratic Republic of the Congo

This is the fifth in a series of seven blog posts highlighting examples and lessons learned regarding the integration of COVID-19 vaccine into primary health care. Read the other posts in the series for more about COVID-19 vaccination integration and examples from other health areas.   

VillageReach is a global health organization working with governments to build systems that deliver health products and information to the hardest-to-reach people, and through collaboration with the private sector and partners, drive sustained impact at scale. VillageReach has worked in the DRC since 2015. 

In 2021 and 2022, VillageReach operated four COVID-19 high-volume vaccination sites (locally known as vaccinodromes) in Kinshasa, in collaboration with the Ministry of Health. In July 2022, VillageReach supported the MOH with DRC’s first COVID-19 vaccination integration with routine immunization at select health facilities.  We spoke with Carla Toko, VillageReach’s Advocacy & Communications Senior Manager, about the lessons learned from this integration experience. 

What was the impetus for integrating COVID-19 vaccination with routine immunization in the facilities where you operated in Kinshasa?   

We operated COVID-19 mass vaccination sites in public places such as football fields, but we knew that these sites only responded to a short-term specific need; we believed that integration was the long-term solution to promoting COVID-19 vaccination. Integration became a point for us because we needed to transfer those operations that were in public places to primary health-care facilities. Secondly, while the strategy for vaccine rollout initially focused on mass vaccination campaigns, at the beginning of 2022, the government had suggestions for integrating COVID-19 vaccination into routine immunization. That’s how, working closely with the government, we started closing the vaccinodrome sites in public places and integrating COVID-19 vaccination into routine immunization at primary health-care facilities.   

We were also motivated by the opportunity of seeing how integration would work when we apply lessons learned from COVID-19 vaccination to routine immunization and apply some of the best practices from routine immunization to improve COVID-19 vaccination.  

Finally, as an organization, it is our practice that when we develop solutions or start projects, we may lead them in the initial stages, but in the long run, for sustainability purposes, we transition them to the government. The integration of COVID-19 vaccination into routine immunization was a sustainable way of handing over COVID-19 vaccination programs to the government. 

What worked well with this integrated service delivery approach? 

The public health facilities where we transferred COVID-19 vaccination were already providing routine immunization, so COVID-19 vaccination was simply an additional component. We used our resources – human, financial and material for COVID-19 vaccination to improve routine immunization services. For every primary health-care facility where integration happened, there were activities done such as renovations on the facilities so we could have both routine immunization and COVID-19 vaccination services in the same area. This ensured that when parents brought their children for immunization, we could encourage them to get vaccinated for COVID-19 in the same visit. This was important because if both services are provided but in different areas, you could refer such individuals to those different areas, but you could still miss them; they could get lost, be discouraged, or leave the site without being vaccinated. We ensured that the services were offered in the same area, so we did not miss out on any adults who were sensitized during routine immunization sessions. 

In addition, we applied the best practices and strategies we used in COVID-19 vaccination such as the use of community health workers and the use of tools such as paper tokens – these tokens were provided to community members as a way of referring them for vaccination to boost routine immunization and COVID-19 vaccination. We had highly motivated community health workers; they not only promoted COVID-19 vaccination but helped identify zero-dose or under-immunized children. They were closer to households and conducted door-to-door outreach to identify vaccine-eligible individuals, whether children for routine immunization or adults for COVID-19 vaccination, so we were able to vaccinate more people. The vaccination sites, outreach activities, and integrated primary health care facilities administered 229,983 (33%) of COVID-19 vaccines in Kinshasa. Of these, 53% were referred by community health workers. Across three integrated primary health-care facilities, 998 under-immunized children received routine immunization, of whom 126 were zero-dose children, as a result of the integrated work. 

What was the biggest challenge you faced in integrating and scaling up both sets of immunization services?  

We operated in different health zones within Kinshasa and each zone had its own context that we had to adapt to if we were to effectively roll out both sets of immunization services. For example, the first vaccinodrome site we integrated was on a football field, so when we moved operations to a primary health-care facility in a residential neighborhood, people could not easily locate it to get services. That’s why we had to ramp up door-to-door outreach knowing that the health facility was not in such a visible location compared to the football field. For the second site, the primary health-care facility was very close to one of the major busy roads with lots of traffic – more visible than the first site – but even then, we needed another approach to reach people in the markets among other areas where we would find more mothers with their children for immunization. 

You did a rapid appraisal of the integration activity. What did you find?  Will this type of integration be sustainable in the DRC? 

The rapid appraisal showed that COVID-19 vaccination continued at the same pace as before we integrated in terms of people who were vaccinated, despite the change from public places to primary health-care facilities. We noted that community health workers played a major role in making referrals during outreach. They provided directions to the facilities. There were also instances when community health workers accompanied mothers and their children to the health-care facilities to get vaccinated and immunized respectively. 

Transferring COVID-19 vaccination to primary health-care facilities is important and sustainable because, compared with short-lived campaigns, health facilities are permanent and continue to provide immunization on a routine basis. So, integration allows us to train health workers and equip primary health-care facilities, which is helpful in the long run because health workers know how to offer vaccines for both adults and children under-five. Also, the fact that both services can be offered in the same area makes it sustainable. 

If someone in another country or context was interested in integrating COVID-19 and routine immunizations in health facilities, what advice would you have for them based on your experience? 

You should be able to adapt your strategy to the local context to be able to provide integrated services. For example, in one of the areas where we did integration, initially, we could not combine COVID-19 vaccination and routine immunization community outreach because there were neighborhoods with populations skeptic of COVID-19. They did not believe COVID-19 existed, and when the vaccines were introduced, they refused to take them up. It took a lot of sensitization for these neighborhoods to accept vaccination. What we heard from the community was that if we tried to combine COVID-19 vaccination outreach with routine immunization, we would have faced stiff resistance from parents against immunization of their children for fear of being vaccinated for COVID-19. So, the promotion of COVID-19 vaccination was done in the communities while routine immunization was done at the health facility. Adapting to local contexts is important. Having social listening skills to know what is being said in the neighborhoods and respond accordingly is important. Among others, you may need to redesign the physical infrastructure of the health facilities for the integrated services to be successful. 

Finally, community health workers are essential because they know the neighborhoods very well and help come up with appropriate strategies. In our case, community health workers helped us identify which households had many children who required immunization but would not send them. Based on this information, we would send out a team in the community to provide the services.   

How if at all, do you think this type of integration will strengthen the overarching health system? 

 We invested a lot in improving data management in primary health-care facilities. We carried out capacity building of health workers such as nurses and doctors operating in the facilities and supportive supervision before rolling out the integrated services. This included revisiting immunization schedules and knowing who is and is not eligible for COVID-19 vaccination, or any other vaccine that may be introduced in the future and dealing with myths and misinformation around immunization and vaccinations.