Public Health
Chad’s immunisation turnaround during the pandemic
By Florian Guiod, Nils Turner, Achta Elimi, Gedeon Ndakmissou
Up until 2017, Chad’s immunisation coverage was one of the lowest in the world. Only around 40% of children received the required doses of vaccines against diphtheria, tetanus, pertussis and haemophilus influenza B (DTC-HibB).

However, this has changed over the past few years. Through a combination of renewed interest from political leaders, greater investment and support from global funders and effective implementation of a data-driven decision making system, the country has achieved tremendous progress, including during the pandemic.

As Amy LaTrielle, Director of Fragile and Conflict-affected Countries at Gavi, the Vaccine Alliance, states “Chad had great successes during the pandemic [...] The differentiated approach [...] combined with strong political commitment and coordinated Alliance engagement and partnership with government out to the subnational levels was beginning to bear fruit.”

In fact, recent initial estimates of DTC-Hib3 coverage by the WHO and UNICEF show that coverage improved to around 58%, by 2021. 

This article captures three of the most critical success factors that helped achieve this.

1.  Solving systematic vaccine shortages

When COVID-19 struck in early 2020, the country was already struggling with endemic vaccine shortages. This was due to two main problems:

  • Little to no funds were being disbursed by the government to pay for vaccines; Chad had used all of its payment facility ceiling and was in debt by one million US dollars.
  • Vaccines stored at the central level rarely reached health facilities because the supply chain was broken

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Fig. 1 - vaccine shortage at the central level in 2019

Partners therefore focused their initial effort on advocating to the Ministry of Health and Ministry of Finance to allocate and release funds for vaccines. Success in this had an immediate effect: in June 2020, Chad fully paid their co-funding for new vaccines and additional funding had been secured for future vaccine orders. Since then, Chad has regularly disbursed funds for vaccines, including over $3 million in 2020. 

Second, significant work was undertaken to fix the supply chain. Supply chain design was reviewed, processes were revised and streamlined in partnership with the program logistics division, contracts were signed with vehicle rental companies and vaccine deliveries were enhanced with digital tracking tools.

Results followed quickly: district shortages fell from 45% to 21% by the end of 2020, and consistently remained low.

 

2. Building an objective and robust performance tracking system

Another key challenge was to ensure the effective use of data for decision making.

It took a joint effort by all major partners to progressively implement a robust supervision and data collection system that enabled access to real-time data from the field on key indicators of the program. The system was piloted in N’Djamena in the summer 2020, then progressively extended to 13 provinces. District managers are now visiting each health facility once a month, and the supervision rate has reached a monthly average of 63% in the 13 provinces.

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Fig. 2 - supervision rates in covered provinces, monthly average for Q2 2022

Built on the Acasus mobile application, the system provides accurate and regular data on indicators like vaccine availability, cold chain availability and functionality, immunisation session performance and community involvement right down to the health facility level. 

More importantly, data from this is converted into actionable insights in the form of data-packs, shared with health managers routinely, and enables them to take decisions and target actions based on evidence from the ground.

 

3. Investing in health facilities and districts

In addition, data collected through supervisions has been instrumental in guiding cold chain equipment, human resource and vehicle investment decisions and planning, another key factor in enabling the successes of the EPI program in Chad.  Examples of such investments that have enabled availability of critical inputs include:

  • Investment in 1195 pieces of cold chain equipment in priority areas, which improved cold chain coverage from 46% to 76%. Cold chain is a key limiting factor to immunisation: areas without cold chain equipment are unable to routinely vaccinate, let alone cover remote communities.
  • Investment in 32 vehicles and 501 motorbikes for mile vaccine delivery and outreach sessions
  • Recruitment of 235 health workers in under-manned areas, reducing the target population/HCW ratio from 269 to 234 and therefore improving equity of access to immunisation services

 

Fig. 3 - target population to health care workers headcount ratio in key provinces

Health areas and districts where these investments were made perform significantly better than others. For instance, districts Koukou Angara and Benoye, where significant investments were made in Human Resources and Cold-Chain Equipment, recorded an increase in children receiving the Penta-3 vaccine of up to 61% and 24%, whereas most other districts where investments were low, struggled to see similar growth rates.

 

The way forward

Despite the challenges and instability the country faces, EPI teams remain committed to now shifting focus from not only ensuring inputs at health facilities and improving management, but also to ensuring there is greater demand in the population for such services.

As the hard work and dedication of the Ministry of Health and partners starts to pay off, there is renewed energy to sustain and enhance performance over the next 12 months.

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