Abstract
BackgroundThe Expanded Programme on Immunisation (EPI) is one of the most powerful and cost-effective public health programmes to improve child survival. We assessed challenges and enablers for the programme in South Africa, as we approach the 2015 deadline for the Millennium Development Goals.MethodsBetween September 2009 and September 2010 we requested national and provincial EPI managers in South Africa to identify key challenges facing EPI, and to propose appropriate solutions. We collated their responses and searched for systematic reviews on the effectiveness of the proposed solutions; in the Health Systems Evidence, Cochrane Library, and PubMed electronic databases. We screened the search outputs, selected systematic reviews, extracted data, and assessed the quality of included reviews (using AMSTAR) and the quality of the evidence (using GRADE) in duplicate; resolving disagreements by discussion and consensus.ResultsChallenges identified by EPI managers were linked to healthcare workers (insufficient knowledge of vaccines and immunisation), the public (anti-immunisation rumours and reluctance from parents), and health system (insufficient financial and human resources). Strategies proposed by managers to overcome the challenges include training, supervision, and audit and feedback; strengthening advocacy and social mobilisation; and sustainable EPI funding schemes, respectively. The findings from reliable systematic reviews indicate that interactive educational meetings, audit and feedback, and supportive supervision improve healthcare worker performance. Structured and interactive communication tools probably increase parents’ understanding of immunisation; and reminders and recall, use of community health workers, conditional cash transfers, and mass media interventions probably increase immunisation coverage. Finally, a national social health insurance scheme is a potential EPI financing mechanism; however, given the absence of high-quality evidence of effects, its implementation should be pilot-tested and the impacts and costs rigorously monitored.ConclusionIn line with the Millennium Development Goals, we have to ensure that our children’s right to health, development and survival is respected, protected and promoted. EPI is central to this vision. We found numerous promising strategies for improving EPI performance in South Africa. However, their implementation would need to be tailored to local circumstances and accompanied by high-quality monitoring and evaluation. The strength of our approach comes from having a strong framework for interventions before looking for systematic reviews. Without a framework, we would have been driven by what reviews have been done and what is easily researchable; rather than the values and preferences of key immunisation stakeholders.
Highlights
The Expanded Programme on Immunisation (EPI) is one of the most powerful and cost-effective public health programmes to improve child survival
In April 2009, South Africa became the first country in Africa to introduce nationwide routine childhood vaccination against rotavirus and Streptococcus pneumoniae; at no cost to recipients
Our objectives were: (1) to determine what EPI programme managers in South Africa consider as key barriers to effective implementation of the programme in the country; (2) to determine what EPI programme managers consider as the best interventions to overcome the identified barriers; and (3) to conduct a comprehensive search of peer-reviewed literature, identify, and synthesise current best evidence on the effectiveness of the interventions proposed by the EPI programme managers
Summary
The Expanded Programme on Immunisation (EPI) is one of the most powerful and cost-effective public health programmes to improve child survival. The Expanded Programme on Immunisation (EPI), which is one of the most powerful and cost-effective public health programmes to improve child survival [14], was introduced in South Africa in 1974. In April 2009, South Africa became the first country in Africa to introduce nationwide routine childhood vaccination against rotavirus and Streptococcus pneumoniae; at no cost to recipients. Despite these advances, there is some evidence that EPI South Africa faces a number of challenges [6,7,8,9]. Our objectives were: (1) to determine what EPI programme managers in South Africa consider as key barriers to effective implementation of the programme in the country; (2) to determine what EPI programme managers consider as the best interventions to overcome the identified barriers; and (3) to conduct a comprehensive search of peer-reviewed literature, identify, and synthesise current best evidence on the effectiveness of the interventions proposed by the EPI programme managers
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