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Immunization Champions: Local solutions for local problems in Palabek Refugee Settlement, Uganda

Immunization Champions link caretakers & health centers to reduce barriers to immunization and improve efficiency of vaccination programs.

Photo of Dorothy Kizza

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Describe what you intend to do and how you'll do it in one sentence (required 250 Characters)

We will identify exemplary caregivers and train them to be Immunization Champions, who will promote immunization practices and coordinate group immunization activities, connecting caregivers with immunization programs at the local health center.

Explain the idea (less than 2,000 characters)

In the midst of recovering from 20+ years of civil war, which displaced 2 million Ugandans, increased civil conflict in South Sudan resulted in a massive influx of refugees from different South Sudanese ethnic groups into Northern Uganda, placing an extra stress on the already weakened Ugandan health care system. As a result, the refugees and host communities experience specific immunization problems, including: (i) skepticism and misinformation about vaccines and about their effectiveness; (ii) stock-outs of vaccines and immunization cards; (iii) low prioritization of vaccines compared to other necessities; (iv) miscommunication between caregivers and the health center; (v) costs and opportunity costs of getting vaccinations. The end users of this project are the children of approximately 10,000 South Sudanese refugees in the Palabek refugee settlement in Northern Uganda, most of whom belong to the Dinka and Nuer ethnic groups. UNHCR (January 2017) approximates that 70% of the refugees are children below 18 years, most of whom have not been immunized. We will promote immunization by providing selected caregivers with the knowledge and tools to become Immunization Champions in their communities. They will encourage their peers to immunize their children and communicate with the health center to ensure that they are prepared to vaccinate the children when they come to the clinic. They will also coordinate the distribution of necessary resources, such as immunization cards. This program capitalizes on the shared culture and life experiences of the refugees, empowering them to improve the health in their own community. It will serve as a model which can be replicated in other refugee settlements, as well as local Ugandan communities. Champions who successfully complete their tasks will receive an official certificate, which will better position them to work in the health sector. We hope that, as a partner, the Ministry of Health will join in awarding the certificate.

Which part(s) of the world does this idea target?

  • Eastern Africa

Geographic Focus (less than 250 Characters)

The idea targets the Lukung zone of the Palabek refugee settlement in the Lamwo District of Northern Uganda, at the border of South Sudan and Uganda, the last Sub-County of Lamwo District. It has nine Parishes and 49 villages.

Who are your end users and how well do you know them? (750 characters)

Our end users are the children of refugees with whom we have worked since 2012. Their assets and strengths include organization, resilience, participation, and commitment to community-driven solutions. Our excellent relationship with the refugees presents opportunities for our innovative immunization model. HealthRight has been involved in community level health development in Northern Uganda since 2006, covering all districts of Northern Uganda for over a decade. We have a country office and staff in Kampala, and five field offices and staff in five districts of Northern Uganda. We are registered with the government and have MOUs with UNHCR, the Ministry of Health, and the Prime Minister, which grant us access to work with the refugees

How is the idea unique? (750 Characters)

Our idea is unique as it: (1) Focuses on refugees - the most marginalized last mile population. (2) Creates local Immunization Champions to promote immunization in their community. (3) Pilots an integrated model, building synergy between care givers and local health systems. (4) Focuses on community-driven solutions. (5) Spreads immunization knowledge via established channels (radio, church). HealthRight is unique because we: (1) Have a history of working with this refugee group. (2) Have existing relationships with leaders in the refugee settlement. (3) Employ staff who share the local culture and languages. (4) Have a human rights-focused mission. (5) Are knowledgeable in local government health systems and refugee support mechanisms.

Idea Proposal Stage (Select 1)

  • Prototype: We have done some small tests or experiments with prospective users to continue developing the idea.

How many months are required for the project idea? (140 characters)

It will take approximately 12 months to initiate and complete our innovative pilot and ensure immunization of approximately 5,000 children.

Organization Name (less than 140 characters)

HealthRight Uganda

Type of Submitter

  • We are a registered NGO or Non-Profit Organization

Organizational Characteristics

  • Female-led organization
  • Women’s health/rights focused
  • Indigenous-led organization
  • Locally/community-led organization

Organization Location (less than 140 Characters)

We are registered with the Ugandan Government. We have a head country office in Kampala and five district offices. Our global HQ is in NYC.

What is the current scale of your organization’s work?

  • Community (working within one or a few local communities within a region)

Website URL

https://healthright.org

Tell us more about your organization/company (1-2 sentences)

We have been in Uganda since 2006, working with the Ministry of Health to respond to the LRA insurgency by using innovative and community-based solutions to improve the mental health and psychosocial well-being of violence-affected and marginalized populations. This project continues our focus on community-driven solutions for marginalized populations, and expands to include prevention against infectious disease, using the experience and expertise gained from our programs in other locations.

Who will work alongside your organization in the project idea? (750 characters)

The project will be implemented in strong partnership with the refugee community, local MOH structures, and in coordination with the Office of the Prime Minister and UNHCR who have jurisdiction over the refugee community in Uganda. Participation of the government will promote the long-term sustainability of the program. Our local field staff will train Immunization Champions and provide them with the necessary resources to succeed in their work. The Champions themselves will be pro-vaccine caretakers, selected from the refugee community, and will be the primary link between their fellow caretakers and the health center. We will work specifically with the district-level Health Centre II, the primary health provider for our target community.

How many people are on your team?

7

Tell us more about you and your team

The Country Director, Joshua Kyallo, is a global health and international development leader with 25+ years of experience at 10+ INGOs. Dorothy Kizza, Technical Consultant, has a PhD in Health Sciences and has been working with this refugee population for 5+ years. Josephine Akellot, Program Director, has 20+ years experience in various departments of health, including vaccine supply chain management systems. Elizabeth Nakanjako is Director of Finance and Admin. Wasereka Samuel, MEAL Coordinator, has a background in health statistics and economics, with experience in organizing monitoring structures for national and international organizations. Julius Kellinghusen has 3+ years of data management and MEAL experience at international organizations. Dr. Sally Guttmacher, Senior Technical Advisor, has worked in South Africa for 20+ years and is an expert on immunization, having served on a Pfizer Pharmaceutical Vaccine Panel from 2012-2017. This core team is supported by 23 field officers.

Overview of How Your Concept Has Evolved (5-6 sentences):

We initially believed that misinformation was caretakers' main barrier to immunization. Using the lessons from Ben Hickler’s webinar, we conducted two pilot studies using a human-centered approach, where we found other barriers specific to this population. For example, health workers will only open a vial of vaccine if there are enough children to use it all up. The feedback from the community also affirmed our idea as a whole – they were excited about the idea of Immunization Champions. Mothers noted that their husbands often influence whether they can take their child to the clinic, so we will actively work to include and sensitize men. As Ben said, pure communication is not enough – there are many little barriers that get in the way.

Viability (3-4 sentences and activity upload):

The strength of the program lies in being implemented by the community which it serves. The project activities include: (1) Educational discussions and workshops to select & train Immunization Champions who represent gender and ethnic diversity. (2) With the Champions (ICs), develop announcements for radio and churches about vaccinations and the services provided by ICs. (3) Enable ICs to facilitate communication between the clinic and caretakers about barriers such as stock-outs. (4) Organize group vaccination trips and remind caretakers or their partners via SMS. (5) Coordinate the trips with the clinic so they are prepared. (6) Follow up monthly with ICs to assess their performance. (7) Gather feedback from the community every 3 months.

Feasibility (3-4 sentences):

In two pilots last week, we interviewed caretakers in a market, around a water pump and at a clinic in the settlement. They were enthusiastic about Immunization Champions and shared their specific challenges to immunization, allowing us to adjust the Champions’ roles to address these issues. For example, at times the health center runs out of immunization cards, and caretakers have to buy booklets to keep vaccination records. This expense prevents some caretakers from immunizing their children. Therefore, giving the Champions a supply of these cards would likely increase the vaccination rates.

Desirability (3-4 sentences and activity upload):

During our pilot, both caretakers and health workers expressed their enthusiasm for Immunization Champions, as they could alleviate some of the challenges they each faced. For example, Champions can help health workers disseminate information – such as when specific vaccines are available. They help caretakers by providing accurate information about vaccines and organizing vaccination trips in coordination with the local health clinic, so that caretakers do not wait in vain at the clinic – e.g. because the vaccine they need is not available that day. Moreover, because the clinic cannot store opened bottles of vaccine and the workers do not want to waste any of it, they only open a vial when there are enough children to use up the bottle.

Community Focus (2-3 sentences):

This project introduces community-driven solutions for sustainable immunization efforts. Because vaccinating children is not a priority in our target community, Immunization Champions will educate the caretakers about the necessity of vaccination and link them to the resources they need to immunize their children. This will be reinforced by public service announcements on the local community radio station and in churches. Because the Champions will represent the various ethnic/language groups in Palabek, they will be able to communicate effectively with their friends and neighbors.

Community Impact (2-3 sentences):

Children's caretakers will understand the importance of immunization and will see it as higher priority. Immunization will prevent young children from contracting dangerous infectious diseases. Immunization Champions can become a function of the local community leadership, continuing to promote vaccination after the program ends. Awarding Champions with certificates based on a pre-established evaluation of their work will better position them to work in the health sector, for example as Community Health Workers. Thus, the program will sustain the promotion of immunization in this community.

12 comments

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Photo of Estela Kennen
Team

Hi Dorothy, I am truly humbled by and thankful for the work your team does. It sounds like various health care system and supply-side issues have been part of the local problem with under immunization; are your partner organizations working to address these issues? (In other words, what happens after the caregivers have increased awareness about vaccines)’?) Also, you mentioned briefly that the project uses data-driven technology; can you talk more about that?

Photo of Estela Kennen
Team

I would also love to hear your thoughts on how to successfully replicate or scale a project that is so rooted in community. (I think this is an interesting problem in general... not particular to your proposal).

Photo of Dorothy Kizza
Team

Dear Estela, during our pilot studies, we learned about the specific barriers that this community faces, some of which involve the supply and use of necessary materials. For example, when the clinic runs out of immunization cards, they ask caretakers to purchase booklets to keep the immunization records. We can easily provide these booklets at what is little cost to us, but a significant cost to the caretakers.

Photo of Dorothy Kizza
Team

Regarding your question about scaling community-based solutions, we have a number of strategies: 1. We are creating awareness and demand at a community level and linking that demand to supply at the local health facility level. 2. We ware building capacity for immunization at the heart of where the problem is, at the same time strengthening the response of the local health facilities and workers, to make sure that as more caretakers bring their children to the facilities, the health workers have the capacity to service them. Therefore, the foundation of this intervention is based on both community systems strengthening and health systems strengthening for immunization. This will enable the primary healthcare system to replicate, scale, and sustain the efforts that we have introduced in the long term - after the project funding is over.

Photo of Ashley Tillman
Team

Estela Kennen great questions and Dorothy Kizza I appreciated your thoughtful answers, I'd be curious to hear a bit more about how you'll identify and train your health champions? With regards to incentives, have you used certificates as an incentive before? Is this enough or are there other ways you plan to help sustain engagement? What are other incentives you've found work in the past?

Photo of Dorothy Kizza
Team

Hi Ashley, great questions – happy to clarify! We will identify champions from the groups of caregivers that attend our focus group discussions. They will be caregivers who are trusted and respected in their communities and who have demonstrated exemplary attitudes and behavior related to health – for example, they had their children vaccinated and can explain the importance of immunization. Of course they also have to be interested in the program and motivated to get their peers to vaccinate their children. These caregivers can be of any age, gender, or ethnic group – in fact we will look for a diverse group of Champions in order to foster personal connections between the Champions and their peers.

We will work with our local field staff, led by Lucy Achan, to develop a short and effective in-person training for Immunization Champions. This will include not only information about vaccinations (how they work, why they are important), but also workshops on communication. For example, how do you have productive conversations with people of different opinions and communicate your perspective?

Training and feedback will be maintained throughout the program via meetings between the Champions and our staff every 2-4 weeks, where we can address challenges as they arise, answer any questions the Champions might have, and incorporate their feedback into the design of the program. We will also link Champions to trainings by the Ministry of Health or other like-minded civil society organizations, to continue to grow their skills and knowledge.

Regarding incentives, certificates are effective incentives used in many different settings around the world, and have been the subject of academic research, including a study by JSI in Ethiopia. Our Technical Advisor Dr. Guttmacher has also used them successfully to reduce the dropout rate of volunteers in an HIV prevention program.

Of course, certificates are not the only incentive of the program – they are part of a collection of social incentives. These include sustained training in health and communication, as well as the public recognition by community leaders and government agencies during the celebration at the end of the program. Most importantly, the knowledge and recognition provided by the program give participating caregivers a stepping stone to a career in the health sector or as community health workers. This will be especially effective for motivating young caretakers who are looking for ways to find paid employment.

As additional incentives, we will outfit each Champion with a t-shirt printed with the text “I am an Immunization Champion!” in each of the languages represented in the settlement. This will build a community between the Champions and develop recognition and social status for the work they are doing. They will also receive a bag (made locally, if possible) with the resources they will need for their work, including additional immunization cards, training guides, and a book to record the work they do. We will use small incentives to maintain participation throughout the program, including bringing food to all meetings with the Champions.

We refrain from using financial incentives because they work only in the short run, are not sustainable, and can lead to conflict between community members who are selected as Champions and those who are not. Moreover, it may attract participants who care more about the money than the work, making the program less effective. The certificates and social incentives are sustainable,encourage participation by caregivers who are invested in the work, and benefit the Champions, as explained above.

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