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Social and Behavior Change Communication Strategy

for the Expanded Program on Immunizations

Namibia

2011 - 2015

1. INTRODUCTION In spite of considerable efforts by the Government of the Republic of Namibia Ministry of Health

and Human Services over the years, immunization rates for children under 5 do not meet

international and national coverage standards of over 90%. The most reliable data from a

household review of children’s cards and mother’s reports is from the 2006-2007 Demographic

and Health Survey. The DHS showed only 68% of children 12-23 months of age to have

received all basic vaccines, with rates ranging to a low of 35.3% in Kunene Region. Data from

National Immunization Days (NIDs) report much higher coverages, however out-dated population

sizes used as denominators and supplementary vaccination of children who are already covered

may over-estimate coverage. Namibia has experienced serious outbreaks in measles, and fears

polio outbreaks as a result of these low rates.

The national EPI program reports the routine immunization program to be weak and need

strengthening. Community level screening and outreach is not conducted regularly as a part of

the routine program, but rather primarily during NIDs. Outreach teams have difficulties reaching

hard to reach areas due to many factors including the inadequate size of teams in some areas, and

lack of appropriate transport. Low coverages in Namibia are also due to social, cultural and

behavioral factors among mothers/caretakers and fathers and communities that are barriers to

immunization. These are detailed for each target population in this document, below.

For these reasons from July 11-13th

2011, representatives from the MOHSS national EPI and IEC

programs met at the UN House with development and civil society partners to develop a National

EPI SBCC Strategy for the period 2011-2015. The workshop was supported by UNICEF and

facilitated by UNICEF and Communication for Change (C-Change) Namibia/USAID.

During the workshop, participants reviewed the EPI situation in Namibia based on current

evidence and experience, selected the principal targeted behavior – full immunization of all

children under 2 and under 5 years of age nationwide – selected 6 principal target audiences, and

developed a strategy to reach individuals and households and communities and address

underlying factors and barriers related to each target group. Participants also defined the

implementation and supervision structure for the National EPI SBCC Strategy 2011-2015, and

selected M&E indicators to measure progress. A way forward was also developed for each level

of intervention over the next 6 months. This National EPI SBCC Strategy will be used by the

MOHSS EPI to inform the development of regional EPI SBCC Strategies and national and

regional plans covering the period 2011-2015.

Participants in the development of the Strategy were as follows:

Martha Spiegel, Khomas Region, ERRC MOHSS

Josephine Mbanga, TEC/MOHSS

A. Gowanas, National level, MOHSS/IEC Division

Mary Muyenga, Otjondjupa Region, MOHSS

P.C. Angala, Otjondjupa Region, MOHSS

F. Hango, Khomas Region, Society for Family Health

H. Hingura, National level, MOHSS

G. Gamuseb, National level, MOHSS

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Fednedy Kabunga, Ministry of Information Technology

Robert T. Nandusa, Omusati Region, MOHSS

Aini-Karin Toiud, Oshana Region, MOHSS

Dorothy N. Kambinda, National level, MOHSS

Martina Allies, National level, MOHSS

Emma Coddin, Blue Cross

Sirka Amambo, Khomas Region, MOHSS/Directorate for Special Programs

S.S. Mungambwa, National level, HPR, IEC Division

Vicky N. Heitee, Khomas Region, MOD/DNF

Carol Ladle, Church of Jesus Christ of the Latter Day Saints

Finelda Khurses, Desert Soul

Michelle Thulkanam, WHO

Paul McNamee, STOP Team, WHO

Lena de Wee, WHO

Facilitators in the development of the Strategy were as follows:

Nance Webber, UNICEF

Elizabeth Burleigh, C-Change Namibia

Stephanie van der Walt, C-Change Namibia

Flavian Rhode, C-Change Namibia

2. EPI PROBLEM STATEMENTS

The following section presents the current situation on immunization in Namibia. Information

was gathered from the 2006-2007 DHS, data from the National Immunization Days, MOHSS

sources and participant experiences.

Current household level data from the 2006-2007 DHS: Coverage of children 12-23 mos. of

age according to vaccination cards or the mother’s report:

95% received the BCG (lowest in Kunene at 74%)

83.2% received the third dose of DPT (lowest in Kunene 51.5%)

89.5% received the third dose of Polio (lowest in Kunene 71.3%)

83.8% received the measles vaccine (lowest in Kunene 60.9%)

68.7% received all basic vaccines (lowest in Kunene 35.3%)

2.2% received no vaccines (lowest in Kunene 13.6%)

73.4% had a vaccination card (lowest in Kunene 49.3%)

National level working group: Problem analysis

The routine vaccine is weak; the focus is on the NIDs

There is poor follow-up on immunizations from the mothers or caregivers

There is also non-compliance on immunizations from mothers and caregivers

Services at health facilities are not readily available during the week or weekends

There is a lack of professional support from the Medical Council, Nursing Council (lack of

technical support or support during national events)

There is no flow of EPI information from the private sector to the MOHSS

Messages on EPI to mothers and caregivers differ between the MOHSS and private

doctors

The MOHSS has not set national EPI standards that must be followed by all providers

including the private sector

There is poor communication on EPI between government and private providers and

within the MOHSS itself

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The NID policy requires 100% coverage. This is a policy issue as the NIDs include the

revaccination of those with full coverage (often higher income groups) focusing NID

resources away from those who lack immunizations (often the lower income harder to

reach areas)

There is a lack of involvement of other line ministries during NIDs and in the routine

immunization program

There is a need to reach audiences through various channels rather than only through the

NIDs. There include meetings at church, schools, through radio, TV, traditional leaders,

civil society, other line ministries and development partners

Regional working group: Problem analysis

Coverage varies by region, for instance:

o Kavango has 47.7% coverage for all basic vaccines

o Kunene has 35.3% coverage for all basic vaccines

o Omusati has 81.0% coverage for all basic vaccines

Underlying problems also vary by region:

o In some regions, children are not taken for immunization due to nomadic lifestyles

(Notably among the OvaHimba and San and those moving back and forth between

Namibia and Angola)

o Some groups lack knowledge regarding immunizations

o Some have cultural beliefs that oppose immunizations

o The economic status of some households limits access to EPI

o Low education/literacy in some households limits knowledge and understanding of the

need for immunization

o Documentation on EPI is missing in some families

o There is a lack of review of documents by health workers and others to identify those

children who need immunizing, and no plan for follow-up

o Some regions have hard to reach areas due to geographical barriers (mountains in the

OvaHimba area; floods in Caprivi, for example) and little provision is made to reach

them

o NID dates and pensioner pay dates are the same and NIDs also conflict with

production schedules and livelihood activities such as fishing, collection of grass

o Some religious convictions are a barrier to immunization

o On some commercial farms, laborers are not given time to take children to EPI or EPI

staff are not allowed onto the farm to immunize

o Data on immunizations is missing from some individuals

o There is a shortage of EPI staff on all levels

o There is a shortage of EPI transport to conduct outreach (lack of 4x4s)

o There is an unequal distribution of resources to regions for outreach that does not take

the population size or geographical situation into account (all have the same no. of

staff and vehicles)

3. KEY BEHAVIOR TARGETED BY THE SBCC STRATEGY

The following is the key behavior targeted by the National EPI SBCC Strategy 2011-2015:

Complete immunization of all children under 2 and under 5 years of age nationwide

4. PRIMARY TARGET AUDIENCES

The following section lists the six primary target audiences for the National EPI SBCC Strategy

2011-2015:

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Mothers/caregivers and fathers from urban and peri-urban areas with lower levels of

education who do not take their children to immunization or drop out

Mothers/caregivers and fathers from rural areas with lower levels of education who do not

take their children to immunization or drop out

Mothers/caregivers and fathers of children with complete vaccine schedules and private

providers not involved in the NIDs

Cross-border populations

Underserved/hard to reach nomadic/cultural groups (such as the OvaHimba, San)

Policy makers responsible for EPI

5. STRATEGY FOR MOTHERS/CAREGIVERS AND FATHERS FROM

URBAN AND PERI-URBAN AREAS WITH LOWER LEVELS OF

EDUCATION WHO DO NOT TAKE THEIR CHILDREN TO

IMMUNIZATION OR DROP OUT

a. MULTI-LEVEL, MUTLI-CHANNEL STRATEGY TO REACH

INDIVIDUALS AND HOUSEHOLDS IN URBAN AREAS

The following section presents the strategy that will be used to reach individuals and

households in urban and peri-urban areas:

House to house approach in urban and peri-urban areas using the RED

approach, including SBCC

o Selection of community RED volunteers with community involvement

o Training of community RED volunteers in EPI and SBCC

o Community mapping and numbering of households with children under 5

o Assign specific households to each RED volunteer

o RED volunteer household visits to review immunization cards and identify

children under 5 needing immunizations

o RED volunteer coordination with the health facility for outreach to complete the

schedule for all children under 5, and bring coverage to 100%

o RED volunteer follow up with all pregnant women and newborns to ensure that

they are immunized

o RED volunteer social and behavior change education to promote immunizations

among reluctant mothers/caregivers and fathers (using a new IEC material to be

developed)

Community level promotion of EPI through the following channels

o Church papers and announcements

o Public notice boards

o In schools through letters to learners and their families

o Group discussions with women’s groups, youth groups, musician artists and

groups

o Advocacy work through formal structures: councilors, churches, business groups,

youth groups, political parties

o During health days

o Through stakeholders such as NGOs and others

Mass media promotion of EPI through the following channels

o TV

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o Radio, interactive discussions/call-ins

o Newspaper articles

b. UNDERLYING FACTORS The following section presents the principal underlying factors affecting the individual

behavior of this target audience:

Mother/caregiver and father level

o Lack of knowledge regarding the importance of immunizations

o Lack of access to information about EPI

o Lack of money to travel to facilities

o Lack of prioritization of activities and postponement of immunization

o Lack of male involvement in child welfare

Community level

o Cultural beliefs opposing immunization

o Religious beliefs opposing immunization

o Distances far to facilities, even in urban areas

o Misconceptions about immunizations from peers, friends (e.g. danger of vaccines,

rashes from polio vaccine; diarrhea)

Facility level

o Children’s cards not being screened at all opportunities in health facilities

o Newborns not being reported from the maternity ward to EPI for follow-up

o Hours not convenient for people who are working

o Staff attitude is negative

o Lack of initiative on the part of facility staff. Do not want to do house to house

visits especially to hard to reach areas

o Long waiting periods, only one nurse for many clients

o Facility resources are limited (lack of EPI or SBCC staff, EPI refrigerator may be

broken, lack of transport)

o Poor planning on the part of the facility leading to vaccine stock outs

o Lack of community involvement with the health facility

o Lack of community-level supervision of volunteer activities to ensure quality

c. MULTI-LEVEL, MUTLI-CHANNEL STRATEGY TO ADDRESS

UNDERLYING FACTORS

The following section presents the strategy that will be used to address the underlying factors:

Strategy to reduce barriers on the mother/caregiver and father level

o One on one discussions in households through the RED approach and volunteers

o Increase knowledge regarding the importance of immunizations not only among

mothers/caregivers but also involving fathers

o RED volunteers review immunization cards and identify children needing vaccines

through outreach

Strategy to reduce barriers on the community level

o Group discussions in the community including traditional leaders to reduce cultural

barriers to immunization

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o Discussion with pastors and church groups to reduce religious opposition to

immunization

o Coordinated outreach to communities to vaccinate children under 5 lacking

vaccines, identified by RED volunteers

o Group discussions with community groups to address misconceptions about

immunizations among peers, friends (e.g. danger of vaccines, rashes from polio

vaccine; diarrhea)

Strategy to reduce barriers on the facility level

o Screen children’s immunization cards at all opportunities in health facilities

o Registration of newborns in the maternity ward and information to EPI for follow-

up

o Modify operating hours to fit people’s needs including weekends

o Enforce the Patient Charter

o Increase the number of health workers to reduce waiting time

o Consult with staff to improve staff attitude

o Discuss health staff lack of initiative with them and make a plan to implement

outreach in coordination with RED volunteers, including hard to reach areas

o Assist facilities with proper planning and budgeting to avoid stock-outs and other

problems, with community involvement

o Organize supportive supervision of volunteers by health workers using a checklist

to ensure quality services in SBCC

8. STRATEGY FOR MOTHERS/CAREGIVERS AND FATHERS FROM

RURAL AREAS WITH LOWER LEVELS OF EDUCATION WHO DO NOT

TAKE THEIR CHILDREN TO IMMUNIZATION OR DROP OUT


INDIVIDUALS AND HOUSEHOLDS IN RURAL AREAS


households in rural areas:

House to house approach using the RED approach, including SBCC










they are immunized



developed)

o Community level promotion of EPI through the following channels

o Meetings with leaders of churches and traditional leaders who are advocating for

“no need for immunization”

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o Group sessions with people at social gatherings: traditional healers gatherings,

women’s groups for self-help projects, initiation ceremonies, water points

o Involvement of different structures of influence (e.g. political, traditional,

religious)

o Group sessions during men’s forums (e.g. traditional courts)

o Meetings with church groups

o Meetings with teachers and nurses (e.g. literacy programs)

o Meetings with community based health workers and volunteers from NGOs

o Meetings with Village Development Committees

b. UNDERLYING FACTORS The following section presents the underlying factors affecting the individual behavior of this

target audience:


o Lack of knowledge, understanding related to the benefits of EPI

o Language barriers –

o Poverty and unemployment preventing travel to facilities

Community level

o Lack of general community knowledge, understanding related to the benefits of

EPI

o Geographical barriers to reaching health facilities (mountains, rivers, floods, etc.)

o Cultural beliefs preventing immunization

o Religious beliefs preventing immunization

o Community located on a commercial farm, not allowed to leave for immunizations

or farmers do not allow EPI outreach teams onto the farm

Facility level

o Facility operating hours not convenient

o Poor outreach activities regarding the benefits of EPI

o Negative attitudes of volunteers

o Need to improve the attitude of nurses

o Limited outreach services in some areas due to lack of resources (e.g. lack of 4wd

vehicles or other transport for hard to reach areas)

o Limited sharing of information from the health worker to the client

o Limited resources for outreach teams

o Lack of EPI and SBCC staff at the facility level

National level

o Lack of a National EPI Strategy

o Lack of a National EPI Policy

o Current SBCC approaches not effective, need to use methods that will change

behavior, not just knowledge

o Marketing and publicity of EPI lacking

o The current size of outreach teams is not rationally related to the population size

and distances in each district.

o Need for EPI and SBCC staff at all levels (regional, district, community)

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UNDERLYING FACTORS



o Hold open dialogue with mothers/caregivers and fathers through RED volunteers

trained in SBCC and EPI

o Fact sheet distribution to households

o Use of local people from the same culture, community and language group as RED

volunteers

o Translation of IEC materials into the local language

o RED volunteer review of vaccination cards to identify children under 5 lacking

vaccines for outreach


o Group sessions in the community to increase knowledge, understanding related to

the benefits of EPI

o Increased outreach based on gaps in vaccines identified by RED volunteers,

including hard to reach areas

o Sessions with traditional leaders and the community to reduce the impact of

cultural beliefs on immunization

o Sessions with religious leaders and churches to reduce the impact of religious

beliefs on immunization

o Develop translated IEC materials that volunteers can use to guide discussions the

community regarding EPI

o In order to improve access to commercial farms, inform the Farmer’s Union of the

EPI situation and risks, and work together to find an approach to solve the

problem. Advocate with farmers to release their workers or allow the MOHSS

staff in for screening and outreach. Involve the MOA agricultural extension

workers to reach agricultural families.


o Modify facility operating hours in consultation with the communities to improve

access

o Use outreach opportunities to promote the benefits of EPI

o Meet with community volunteers to improve their attitudes, consider some kind of

simple incentives

o Meet with facility staff to improve their attitudes towards EPI and outreach

o Work with health facility staff and community members to determine how to reach

hard to reach areas in spite of limited resources (e.g. explore alternatives – use of

volunteers to immunize, use of mules for transport, etc.)

o Develop IEC materials that facility staff can use to guide discussions with clients

regarding EPI

o Ensure that the outreach team is adequate to reach the population in the district,

taking distances into account

o Assign EPI and SBCC staff on the facility level

Strategy to reduce barriers on the national level

o Advocate for the development of a National EPI Strategy

o Advocate for the development of a National EPI Policy

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o Implement the SBCC strategy for EPI that includes up-to-date approaches to

behavior change including discussion, marketing and publicity of EPI

o Advocate for the size of outreach teams to better reflect population size and

distances in each areas. This will allow teams to reach communities more

effectively

o Advocate for EPI and SBCC staff at all levels (regional, district, community)

9. STRATEGY FOR MOTHERS/CAREGIVERS AND FATHERS OF

CHILDREN WITH COMPLETE VACCINE SCHEDULES, AND

PRIVATE PROVIDERS WHO ARE NOT INVOLVED IN THE NIDS


INDIVIDUALS AND HOUSEHOLDS


households in this target audience:











they are immunized



developed)

Community level promotion of EPI through the following channels:

o Health workers attend existing meetings and present EPI information in

surrounding communities at schools, churches- existing platforms

o Health workers ask groups in the surrounding communities for suggestions

regarding approaches to these households

o Talks should include information about adverse events and address concerns with

data and facts

o The community should be mobilized to participate – groups could sponsor

outreaches in these communities for their members

o Make use of church leaders and ask them to explain to their congregations

o Develop flyers, booklets, leaflets to explain medical terms and reasons for

supplemental doses and why families should bring their children for a second

round

o IEC materials should display the MOHSS, WHO, UNIC EF, Medical Assn,

Medical Society logos

o Develop a national EPI logo and include it as well

o Messages regarding supplemental immunization should also be included in the

yellow child health passports

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o A space should also be put into the child health passports for participation in the

NIDs (or colored dots could be put in the passports if the immunization took place

during an NID)

o Traditional leaders should be informed and included as resource persons

o Community mobilizers implementing group talks and home visits should be from

the community and be respected by the community

UNDERLYING FACTORS The following section presents the underlying factors affecting the individual behavior of this

target audience:


o Lack of understanding of the need for supplementary immunization of children

who are fully immunized

o lack of familiarity with the internationally approved public health approach

o Lack of information regarding national EPI standards

o Fear of adverse events from supplementary immunizations

o Lack of trust in public sector health workers and their knowledge regarding EPI

o Doubts about the quality of the vaccine product

o Doubts about the experience of health workers

o Issues of home safety related to home visits by vaccination teams

Private sector provider level

o Lack of understanding of the need for supplementary immunization of children

who are fully immunized

o lack of familiarity with the internationally approved public health approach

o Lack of information regarding national EPI standards

o Doubting the quality of the vaccine product

o Doubting the experience of the health workers

o Questioning the paperwork and documentation

National level

o Lack of availability of information on Namibian government and medical

association websites regarding EPI

o Lack of two-way communication between the private sector and GRN

b. MULTI-LEVEL, MUTLI-CHANNEL STRATEGY TO ADDRESS

UNDERLYING FACTORS

The following section presents the strategy that will be used to address these underlying

factors:


o Attend meetings of existing community groups and explain the international public

health approach and national EPI standards, the current situation

o Include information about adverse events and address concerns with data and facts

o Make sure health workers are trained and confident, familiar with the content

o Show them international and national policy guidelines so they understand

o Develop and hand out vaccine reference material and contact details in case they

are still doubtful

o ID cards to make it safer, telephone numbers people can call

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o Use trusted members of the community to convince people to allow the

supplemental dose

Strategy to reduce barriers related to private sector providers

The MOHSS and private sector should have meetings to share data, aims and

objectives, respect their input, share gaps and reasons why there are gaps, interact

so that the private sector sees how they can participate

o Make sure they understand that they are part of the implementation process

o Have an open door policy – invite them to MOHSS meetings

o Have open policies and guidelines and update them on what is expected from them

when they come to register – the TOR for their support to communities

o Have health workers visit private providers routinely to collect data, communicate

and show commitment

o Develop a simple tool for reporting, just ticking

Strategy to reduce barriers on the national level

o Develop information on GRN and Medical Association websites, for reference

o Increase communication between the MOHSS and private sector on this level as

well.

10. STRATEGY FOR CROSS-BORDER POPULATIONS




households in this target audience. There is high demand for EPI from this population as

immunizations are often not available in their country of origin. The cross- border population

consists of visitors, those who come to trade or shop, and illegal immigrants.











they are immunized



developed)

Community level promotion of EPI through the following channels:

o Educate the trader population and Namibian shop owners on the importance of

immunizations

o Communicate to this population in local languages

o Distribute information on the location of EPI services and that they are free

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o Hold community cross-border meetings and conduct joint screening and outreach,

especially during national days such as Child Health Days and NIDs

o Advocate that individuals always carry their health passport with them when they

cross the border

b. UNDERLYING FACTORS The following section presents the underlying factors affecting the individual behavior of this

target audience:


o Fears of deportation

o Migrant lifestyle making follow up difficult

o Lack of knowledge regarding EPI

o Little ownership of their health – leave it to the Ministries of Health

o Distances to health facilities

o Language barriers for SBCC and attendance at health facilities

o Cultural factors: belief in traditional healers, prefer over health facilities

Facility level

o Poor planning for outreach visits and NIDs

o Lack of cross-border coordination

o Language barriers between health providers and clients

o Overcrowding and long waits at facilities

o Cultural differences between health providers and clients

o Inadequate record keeping to avoid excessive revaccination


UNDERLYING FACTORS



o Hold meetings with groups and individuals in communities and households to

address their fears of deportation, increase knowledge regarding EPI

o Hold meetings with traditional leaders and healers on both sides of the border to

reduce barriers to EPI related to cultural factors

o Develop IEC materials in appropriate languages on the subject of EPI and use

those with groups and individuals

o Address migrant lifestyle and distance barriers through increased outreaches to

these groups, in cross-border coordination


o Map villages on both sides of the border in a joint exercise with EPI staff from the

bordering country(ies)

o Gather data from this population on both sides of the border regarding the need for

immunizations

o In the joint plan, conduct better planning for logistics (e.g. enough staff, vehicles or

other transport)

o Plan for joint outreach on both sides of the border to complete immunizations

among children under 5, including hard to reach areas

o Determine specific dates for specific points for NIDs

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o Develop adequate record keeping to avoid excessive routine revaccination

o Use IEC materials in appropriate languages on the subject of EPI and use those

with groups and individuals to reduce language and cultural barriers

11. STRATEGY FOR UNDERSERVED/HARD TO REACH GROUPS

(OVAHIMBA, SAN, NOMADIC, ORSIRE CAMP)




households in this target audience:











they are immunized



developed)

Community level promotion of EPI through the following channels

o All community SBCC to be implemented by trained volunteers from the targeted

communities to reduce language and cultural barriers

o Where SBCC is implemented by health workers, interpreters will be used

o Work though headmen to get their understanding and buy-in, support and ideas for

increasing vaccination coverages

o Meet with leaders councils, TBAs to explain EPI and the risks and get their support

and ideas for reaching mothers/caregivers and fathers

o Meet with groups during Osire camp

o Hold group discussions on EPI around the fire at night

o Meet with and discuss with water point committees

o Hold discussions in market places

o Hold discussions during auctions

o Meetings in churches, schools and mobile schools, clinics, with peer groups

o Group discussions during initiation ceremonies and weddings

o Discussions during soccer matches

o School drama followed by discussions in the local language

Mass media

o Radio TSA!

o Audiovisual in the local languages, accompanied by facilitated discussion

b. UNDERLYING FACTORS

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The following section presents the underlying factors affecting the individual behavior of this

target audience:

Mothers/caregivers and fathers

o Alcohol abuse causing child neglect, lack of immunizations

o Lack of knowledge regarding immunizations and their importance

o Family focus on other priorities such as survival, food, not EPI

o Poverty – no means to reach the clinic, transport

o Fear of people they do not know, not of their culture

o Lack of knowledge of human rights – that health care is a human right

Community level

o Remoteness – far from health facilities (e.g. 7-8 hrs even driving, some have to go

through Khaudum Park)

o Cultural, traditional norms and beliefs – can’t be over emphasized.

o Marginalized lifestyles (e.g. stay to themselves, migrant lifestyle)

o Impact of churches (e.g. in Kavango Andara District local churches refuse to bring

children to be vaccinated)

o Lack of role models (e.g. no one as a role model to motivate the community to go

to the health facility)


UNDERLYING FACTORS


Strategy to reduce barriers on mother/caregiver and father level

o Train people from the community as volunteers to work in EPI and SBCC and

work with households and groups – this will deal with the fear of people they do

not know, and language and cultural barriers

o Use IEC materials in the local languages to discuss EPI and human rights (Patient

Charter)

o Encourage them to demand services

o Volunteers to visit households to provide SBCC and screen cards

o Organize targeted outreach based on findings of screening to complete vaccination

schedules among children under 5 – this will increase access and deal with barriers

of poverty and distance


o Increase outreaches, including hard to reach areas to deal with problems of access

o Use trained community volunteers who are from the same culture and language to

work with community groups

o Advocate with community and traditional leaders for EPI and to reduce alcohol

abuse

o Take advantage of social gatherings where children are present to provide SBCC

and immunize children

o Create awareness through social mobilization during community and traditional

events

o Involve communities through joint planning, implementation and evaluation of

immunization status, gaps and outreaches

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12. STRATEGY FOR POLICY MAKERS RESPONSIBLE FOR EPI

Development of a National EPI Strategy and National EPI Policy

As a matter of priority, the policy group felt it was important for Namibia to develop an overall

National EPI Strategy and an EPI Policy.

a. Background

Namibia has endorsed the WHO Red Strategy and GAVI. Routine immunization covers 6

vaccines: TB, diphtheria, whooping cough, tetanus, polio and measles. The current situation

is as follows:

National immunization coverage is approximately 92% in 2010

Of the 13 regions in Namibia, only Omusati (82%) has achieved above 80%.

Numerous regions have very low coverages of between 30 – 60% such as Kavango

(47%); Kunene (35%); Ohangwena (70%); Omaheke (70%).

Coverage data may be inaccurate due to out-dated population data and that it only

captures those children with vaccination cards.

The data also does not show coverages at district level to provide a more detailed

picture.

b. Key issues that need to be addressed in an overall national EPI strategy

Human Resources: Expansion of EPI structure at all levels

Posts must be created for regional EPI managers and district EPI officers /

managers

Each region and district should have an SBCC/health promotion/Social

Mobilization officer

Training and Capacity Building

There should be frequent training and capacity building on how to communicate to

communities regarding the safety of vaccines (e.g. need for booster doses, etc.)

Outreach Services

Ensure that a dedicated EPI health worker is part of PHC outreach mobile teams

Use the RED Strategy to ensure that every child in every house is reached,

screened and immunized

Establish EPI routine/outreach services that are organized when and where people

gather: during weekends and after-hours. This means that EPI/outreach services

need to work flexi-time or incentives such as overtime must be provided.

Multi-sectoral Approaches

Empower the EPI program to use other line-ministerial resources for EPI outreach

to increase coverages (transport, human resources for screening)

Explain the roles and responsibilities of various partners (e.g. private medical

bodies, FBO’s, labor organizations, etc.)

Need to institutionalize EPI across sectors

Document this with partnership agreements

SBCC/communications Strategy

The SBCC/communications Strategy section of the national EPI strategy document

should be based on this National SBCC EPI Strategy document and include

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advocacy on high levels with strong evidence, challenges, and explaining what is

required

The nationals strategy should involve someone high to endorse such as PS or First

Lady.

The strategy should also use the media and human interest stories of those

immunized and not immunized.

c. Key issues that need to be addressed in an EPI Policy

Role of multi-sectoral stakeholder involvement

Multi-sectoral involvement: Line ministerial support to EPI via advocacy and

sharing of resources.

Private Stakeholders (e.g private doctors to endorse and support routine and

supplementary routines)

Associations (e.g. Medical Association of Namibia; HPCNA; NCCI etc.) to

endorse and rigorously participate in planning, development and implementation as

well as evaluation of EPI

Political Leadership role in advocating for finalizing an EPI strategy and policy

developed.

Faith-based organizations to endorse EPI

Labor organizations such as farmer unions, labor unions, etc to enable and support

parents to immunize their children.

Human resources

Each region and at district level should have an SBCC/communications/social

mobilization staff member to integrate SBCC into EPI planning, implementation

and monitoring/supervision

Nurses job description should also stress the importance of EPI – screening at all

opportunities

Cross border health approach

Synchronized and consistent immunization approach

Initiate a process for checking immunization cards/ health passports when entering

the border similar to yellow-fever.

Need to assess and look at International Health Regulations (IHR)

Integration of EPI among other health services

EPI should be integrated into other health services to reduce duplication and ensure

coverage. For instance: Allow health workers doing ante-natal care, PMTCT, etc to

provide immunization services.

Mobile outreach teams should also include EPI

RED approach

Empower regions and districts to use the RED approach to reach every house.

Resource mobilization

Lack of both human and financial resources pose huge challenges for scaling up

and/or reaching the unreached.

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The national EPI program needs to be empowered to use other line ministries’ to

support by sharing vehicles, staff, etc.

Recording of health passport

A message on supplementary NIDs should be included in the health passport

Health passports should record both rounds

d. Primary Audiences

The primary target audiences for EPI Strategy and Policy development will be the ICC,

policymakers, cross border health officials, the government treasury and other line ministries

(e.g. trade, home affairs, etc.)

Activities to reach the primary target audiences

The following are activities that will be conducted to reach these audiences:

Consultative meetings with multi-stakeholders including cross-border health

officials to engage and develop the national EPI strategy and policy (e.g.

stakeholder meetings: NCCI; MCH Committee; NPC, Economizing Meetings to

push the agenda)

Sensitization of the national council and national assembly regarding the need for a

national EPI strategy and policy.

Enlist a high level supporter and advocator to influence such as the First Lady

e. Secondary Audiences

The secondary audiences for EPI strategy and policy development will be those that can put

pressure for EPI (e.g. church leaders, traditional authorities, health workers, private sector,

etc.)

Channels of communication to reach the secondary audiences

Use media to raise awareness about EPI issues via:

o TV, Radio

o Newspaper

o Conferences

f. Key Behavior Change Messages(s)

Key messages should include the following:

Note competing policy priorities –

Need to link EPI with other strategies and policies (e.g. how EPI will improve

Maternal Child Health, the MDGs, etc.)

13. ADVOCACY AND PARTNERSHIPS FOR IMMUNIZATION The following section describes the partnerships and advocacy that will be necessary for the

implementation of the National EPI SBCC Strategy 2011-2015.

Advocacy and partnerships on the community level

1. Advocate and provide human, financial and logistical support: Headmen, NGOs,

governors, Blue Cross, business community

2. Ensure effective planning (place, time, and location) for immunization sessions for

routine, outreach and mobile: TBAs, community nurses, nurse corps, partners

3. Identify and refer newborns: TBAs, community nurse corps

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4. Track and follow up on defaulters: Community nurses, village health workers,

headmen, councilors

5. Publicize immunization sessions: NBC radio, focus group discussions, churches,

schools, governors

6. Develop advocacy and mobilization messages (that resonate with the community):

Community nurses, councilors, HEWs, village health workers, volunteers

7. Assist with transport and other resources: Community members, churches, schools,

community, business groups, small businesses, coops groups, TBAs, CBOs

8. Encourage and train volunteers to assist at immunization sessions: Village health

workers, community nurses, councilors, community leaders, CBOs

9. Communicate with local people and inform health officials about suspected vaccine-

preventable diseases and adverse events following immunization: Community nurses,

trained health volunteers, NBC, local newspapers

10. Monitor the immunization program by going through the coverage data with the health

team: Volunteers, councilors, CBOs

Advocacy and partnerships and the national level

Role of multi-sectoral stakeholder involvement

o Multi-sectoral involvement: Regional councilors, governors

o Private Stakeholders: PS and Undersecretary of Health, in communities work with

chairs of different bodies so they sensitize their branches

o Political Leadership role in advocating for finalizing an EPI Strategy and policy:

PS of Health, regional directors, community structures and chiefs

o FBOs: PS and Undersecretary of Health, Council of Churches, pastors on

community level

o Labor orgs: PS and Undersecretary of Health, farm unions and labor unions in the

regions to reach their members

Human resources:

o HR: each region and district level should have EPI and social mobilization/SBCC

staff or focal point to integrate SBCC into EPI. District to Regional Directors to

Chief Regional Officer to Regional Development Committee, community leaders

and stakeholders

o Nurse job description: EPI already integrated

Integration of EPI among other health services

o Integration into other health services: this is already done, including clinical and

outreach services

RED approach

o RED approach empowerment: should start with the national level to regional to

community health committees and volunteers.

o An integral part of this SBCC Strategy for EPI for all target groups.

Resource mobilization

o Social mobilization: PS writes to other PS to in other ministries (e.g for use of

transport during NIDs, etc.)

Recording of health passport

o Recording of health passport, NID information both rounds: Director of PHC

informs the PS and Undersecretary of Health who inform the regional directors to

strengthen this recording on the passports.

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14. IMPLEMENTATION

The following section lists the individuals principally responsible for implementing the National

EPI SBCC Strategy 2011-2015, for each level of implementation:

National level

o President of the Nation

o Prime Minister

o Cabinet

o MOHSS Primary Health Care

o MOHSS/EPI Division and staff

Regional level

o Regional Governors

o Regional Development Committees

o Regional Management teams

o Regional Health Committees

o Regional MOHSS EPI and SBCC staff

District and constituency levels

o Constituency Development Committee

o District MOHSS EPI and SBCC staff

Facility level

o Health workers

o Health Committee members

o Community mobilizers and trained RED volunteers

Community level

o Village Development Committees

o Community mobilizers

o Trained community RED volunteers

o Health workers

Individual and household level

o Community mobilizers

o Trained community RED volunteers

o Health workers

15. SUPERVISION

The following section explains how the National EPI SBCC Strategy 2011-2015 will be

supervised to ensure quality SBCC interventions:

National level

o The national EPI staff will make quarterly team visits to the regions with other

program staff

Regional level

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o The regional EPI and SBCC staff including the Chief Medical Officer and Chief

Health Administrator will make quarterly visits to the districts

District and constituency levels

o The district EPI and SBCC staff including the PMO and Primary Health Care

Supervisor will make quarterly visits to the health facilities

Facility level to the community level

o The facility health nurse will make monthly visits to each of the outreach points to

monitor EPI activities being conducted by community mobilizers and RED volunteers

o Visits will include observation of SBCC sessions to ensure quality based on the use of

a standard support supervision checklist (to be developed)

16. BEHAVIORAL M&E

The following is a list of indicators proposed to measure the outputs and outcomes of the National

EPI SBCC Strategy 2011-2015:

Monitoring commitments

1. Mechanism in place to coordinate communication planning and monitoring

2. Advocacy strategy in place to empower and include both local and traditional leaders

Global indicators

1. % of working groups in high risk areas utilizing social data for communication planning

2. % of caregivers aware of routine immunization schedule

Advocacy

1. # of districts with EPI review meetings conducted; meetings chaired by district leadership;

data on communication presented

2. # of ICC meetings per year chaired by the Ministry of Health

3. % of the budget for the communication plan and budget funded by government

Program

1. # of children from high risk populations immunized as a proportion of the total number of

children in high risk populations

2. % reduction in drop out in high risk districts (annually)

Communication

1. % of districts with communication plans in place, including plans for reaching the high risk

populations

2. # of HR districts with updated social maps in place which include identification of high risk

populations

3. # of health districts where micro-planning is taking place

4. # of HR health districts where mobile, migrant and underserved populations and their

movement patterns are identified and covered by communication

5. % of caregivers who can state the number of times an infant should be taken to the health

facility before its first birthday for immunization (target 95%)

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17. WAY FORWARD The following section presents the way forward determined by participants for the next 6 months.

These points will be taken into account in the development of the first year action plan.

National level

Brief the PS and management group on the National EPI SBCC Strategy 2011-2015

Brief the MCH committee on the National EPI SBCC Strategy 2011-2015

Brief the National Management Planning Meeting on the National EPI SBCC Strategy

2011-2015

Sensitize the regions on the National EPI SBCC Strategy 2011-2015 during the week of

the evaluation of the 2nd

round of NIDs

Make a presentation to the ICC on the National EPI SBCC Strategy 2011-2015 to get

commitment at the next quarterly meeting

Fast track the development of a National EPI Strategy which should include the National

EPI SBCC Strategy 2011-2015 as part of the document

Fast track the development of a National EPI Policy and Guidelines

Learn from the RED strategy experience in the 7 districts and roll out the RED strategy to

all regions

Integrate SBCC into the RED strategy

Develop a simple SBCC tool (IEC tool such as a flipchart) for group and individual

discussions to improve knowledge and change behavior

Develop a training curriculum including SBCC for community volunteers who will

implement the National EPI SBCC Strategy 2011-2015

Develop a standard checklist for support supervision covering not just EPI but all technical

areas, ensuring that it includes SBCC quality

Advocate with Parliament for EPI

Sensitize Junior Councilors on EPI

Brief Regional Directorates at the Management Meeting

Hold a 3-day meeting with regional partners to develop regional EPI SBCC strategies and

action plans, using this one as a guide

Sensitize regions and give them a TOR for inter-agency committees

Re-address the question of outreach staffing in each district so that team sizes take the size

of the district and distances into account

Advocate for changes in facility hours to improve access

Regional level

Establish regional inter-agency EPI committees

Regions to develop regional EPI SBCC strategies with this one as a guide

Involve regions in the development of a simple SBCC tool (such as a flipchart) for group

and individual discussions to improve knowledge and change behavior

Develop a standard checklist for support supervision covering not just EPI but all technical

areas, ensuring that it includes SBCC quality

District level

Develop TORS for all levels of implementation

social and behavior change communication strategy for the ... · the national epi program reports...

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