Abstract
BackgroundGoverning immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. In one of the Indian states, Kerala, after routine immunization had reached high coverage in the late 1990s, it started to decline in some of the districts. This paper describes an application of complex adaptive systems theory and methods to understand and explain the phenomena underlying unexpected changes in vaccination coverage.MethodsWe used qualitative methods to explore the factors underlying changes in vaccination coverage in two districts in Kerala, one with high and one with low coverage. Content analysis was guided by features inherent to complex adaptive systems such as phase transitions, feedback, path dependence, and self-organization. Causal loop diagrams were developed to depict the interactions among actors and critical events that influenced the changes in vaccination coverage.ResultsWe identified various complex adaptive system phenomena that influenced the change in vaccination coverage levels in the two districts. Phase transition describes how initial acceptability to vaccination is replaced by a resistance in northern Kerala, which involved new actors; actors attempting to regain acceptability and others who countered it created several feedback loops. We also describe how the authorities have responded to declining immunization coverage and its impact on vaccine acceptability in the context of certain highly connected actors playing disproportionate influence over household vaccination decisions.Theoretical exposition of our findings reveals the important role of trust in health workers and institutions that shape the interactions of actors leading to complex adaptive system phenomena.ConclusionsAs illustrated in this study, a complex adaptive system lens helps to uncover the ‘real’ drivers for change. This approach assists researchers and decision makers to systematically explore the driving forces and factors in each setting and develop appropriate and timely strategies to address them. The study calls for greater consideration of dynamics of vaccine acceptability while formulating immunization policies and program strategies. The analytical approaches adopted in this study are not only applicable to immunization or Kerala but to all complex interventions, health systems problems, and contexts.
Highlights
Introduction of Universal Immunization Programme (UIP)Strong political commitment to immunisation, extensive organisation for the delivery of immunisation service, weekly immunisation.Improvement in vaccine acceptability
Though UIP has improved the availability of vaccines and cold chain management compared to earlier immunization programs, the system has not yet achieved sustained improvement in vaccination coverage in many Indian states [2,3]
As described in the introductory section, our analysis of trends in immunization coverage in both districts showed a sudden decline in immunization coverage in Kozhikode; based on three rounds of the District Level Household and Facility Survey, Kozhikode showed a decline after the second round of the survey in the 2002–2004 period
Summary
Introduction of UIPStrong political commitment to immunisation, extensive organisation for the delivery of immunisation service, weekly immunisation.Improvement in vaccine acceptability. It has been slated as a mechanistic approach, which was simplistically expected to improve immunization coverage through the improvements in health infrastructure, financing, supplies, and better management practices [4,5] This approach has typically failed to account for the unique characteristics, interactions, and needs within local systems and the diversity of actors impacting a household’s decision to vaccinate. Such an approach was often constrained by a lack of understanding of the complex behaviour of local health systems, which often do not respond as expected to external interventions and policies. Such an approach can only provide a limited explanation for fluctuations in immunization coverage rates, over time
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